History and background of patient safety and quality Flashcards
What is patient safety?
The freedom from accidental injury due to medical care or from medical error.
Who found that very poor care was given for wounded soldiers?
Florence Nightingale
Who begun to implement some evidence-based practices like hand washing and improving ventilation?
Florence Nightingale
Founder of evidence-based medicine:
Dr Ernest Codman
Who implement that doctors and hospital staff should follow up with all patients and limiting staff membership of well-educated:
Dr Ernest Codman
Who is considered the father of patient safety:
Avedis Donabedian
Who said “NOT bad people but BAD systems”
Avedis Donabedian
What are the four strategies for improvement a safer
healthcare system:
- Enhance the knowledge (w/ leadership, research, tools and protocols)
- Developing mandatory reporting systems
- Raise performance standards and expectations for improvement in PS
- Implement safety systems in HC organizations
Who explains how faults in different layers of a system lead to incidents:
James Reason
What is a forcing functions?
Something created to make it impossible to a HCP make a mistake
What are the Steps to minimize medical error:
- Forcing function
- Automation and computerization
- Simplifications and standardization
- Checklist and double checklist
- Rules and polices
- Education and training
Example fo a forcing function:
oxygen and medical wires
Example of a constraints:
colored oxygen wires
Example of Simplification and standardization:
apps for patient information
