Informatics 10: Patient Safety-Related Definitions

Question 1

safety

Answer 1

-minimization of the risk and occurrence of patient harm events

Question 2

harm

Answer 2

-inappropriate or avoidable psychological or physical injury to patient and/or family

Question 3

adverse events

Answer 3

• an injury resulting from a medical intervention

- coming out worse than you were

Question 4

preventable adverse events

Answer 4

-errors that result in an adverse event that are preventable

Question 5

overuse

Answer 5

• the delivery of care of little or no value
• widespread use of antibiotics for viral infections
• cover your ass

Question 6

underuse

Answer 6

• the failure to delivery appropriate care

- vaccines and cancer screening

Question 7

misuse

Answer 7

• the use of certain service in situations where they are not clinically indicated
• MRI for routine low back pain

Question 8

most common medical errors

Answer 8

• prescribing medications*
• getting the correct laboratory test for the correct patient at the correct time
• filing system errors
• dispensing medications and responding to abnormal test results

Question 9

Health information technology (HIT) could…

Answer 9

• improve communication physicians and patients
• improve clinical decision support
• contribute to a decrease in diagnostic errors

Question 10

HIT and medical errors

Answer 10

• errors occur more often due to inadequate systems and not inadequate individuals -> system was programmed wrong
• fee-for-service system did NOT traditionally reimburse based on quality or patient safety
• cost $1 trillion dollars annually in US alone

Question 11

Crew resource management (CRM)

Answer 11

• based on airline crew
• focuses on interpersonal communication, situational awareness, leadership and decision making
• adopted by a number of hospitals
• operating rooms employ a CRM-based check list prior to initiating surgery -> reduce mistakes
• first specialty to experience dramatic advances in patient safety was anesthesiology, with less than one death in 200,000 patients undergoing anesthesia

Question 12

meaningful use and impact on patient safety

Answer 12

• objective: use computerized provider order entry (CPOE) for medication, laboratory, and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines
• objective: use clinical decisions support to improve performance on high-priority health conditions
• objective: automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR)
• objective: generate and transmit discharge prescriptions electronically (eRx)
• if you go against the computerized decision support -> you must justify

Question 13

institute of medicine (IOM) reports

Answer 13

• congress should create a center for patient safety within the agency for healthcare research and quality
• a nationwide reporting system for medical errors should be established
• volunteer reporting should be encouraged
• congress should create legislation to protect internal peer review of medical errors
• performance standards and expectations by healthcare organizations should include patient safety
• FDA should focus more attention on drug safety
• healthcare organizations and providers should make patient safety a priority goal
• healthcare organizations should implement known medication safety policies

Question 14

IOM- 2003

Answer 14

• patient safety must be linked to medical quality
• a new healthcare system must be developed that will prevent medical errors in the first place
• new methods must be developed to acquire, study and share error prevention among physicians, particularly at the point of care
• the IOM recommended specific data standards so patients safety-related information can be recorded, shared and analyzed
• be proactive not reactive

Question 15

IOM- 2011

Answer 15

• health IT and patient safety: building safer systems for better care
• report focused exclusively on health IT as it related to patient safety and quality
• publish health IT vendors to support the free exchange of information about health IT experiences and issues
• public and private sectors to make comparative user experiences publicly available
• health IT safety council to assess and monitor safe use of health IT and its use to enhance patient safety
• specify the quality and risk management processes that health IT vendors must adopt
• establish and independent federal entity to investigate patient safety deaths, serious injuries, or potentially unsafe conditions associated with health IT
• support cross-disciplinary research toward the use of health IT as part of learning system

Question 16

heatlhGrades 2020 patient safety excellence awards

Answer 16

• lowest occurrences of 14 preventable patient safety events
• 14!!!!*
• must be the lowest in all 14
• death rate among surgical inpatients with serious treatable complications
• death rate in low morality diagnosis related groups (DRGs)
• pressure ulcer rate
• iatrogenic pneumothorax rate
• central venous catheter-related bloodstream infection rate
• postoperative hip fracture rate
• postoperative hemorrhage or hematoma rate
• postoperative acute kidney injury requiring dialysis
• postoperative respiratory failure rate
• postoperative pulmonary embolism or deep vein thrombosis rate
• postoperative sepsis rate
• postoperative wound dehiscence rate
• accidental puncture or laceration rate
• retained surgical item or unretrieved device fragment count

Question 17

Department of health and human services

Answer 17

• agency for healthcare research and quality (AHRQ)
• center for medicare and medicaid services (CMS)
• hospitals must assemble, analyze, and trend clinical and administrative data to capture baseline data and measure improvement over time
• health IT-based interventions are expected to assist

Question 18

center for medicare and medicaid services (CMS)

Answer 18

• non-reimbursable complications included:
• objects left in a patient during surgery and blood incompatibility
• catheter-associated urinary tract infections
• pressure ulcers (bed sores)

Question 19

quality care finder

Answer 19

-allows consumers to review quality metrics e.g. morbidity and mortality making decisions

Question 20

office of the national coordinator for HIT

Answer 20

• learn: increase the quantity and quality of data and knowledge about health IT safety
• improve: target resources and corrective actions to improve health IT safety and patient safety -> Safety goals will be aligned with meaningful use objectives
• lead: promote a culture of safety related to health IT

Question 21

food and drug administration (FDA)

Answer 21

• medwatch
• center for devices and radiological health (CDRH)
• plan to regulate mobile medical applications designed for use on smartphones
• state patient safety programs

Question 22

national patient safety foundations (NPSF)

Answer 22

• non-governmental organizations
• identifying and creating a core body of knowledge
• identifying pathways to apply the knowledge
• developing and enhancing the culture of receptivity to patient safety
• raising public awareness and fostering communication around patient safety
• improving the status of the foundation and its ability to meet its goals

Question 23

patient safety

Answer 23

-direct relationship with quality

Question 24

other organizations

Answer 24

• the national quality forum
• the joint commission- national patient safety goals -> watch and monitor quality
• leapfrog group- pediatrics quality insurance

Question 25

safe medication practices

Answer 25

• 5 rights of medication safety
• right drug
• right patient
• right dosage
• right route
• right time

Question 26

technologies with potential to decrease medication errors: CPOE

Answer 26

• computerized provider order entry (CPOE):
• inpatient or outpatient
• improved handwriting identification
• reduced time to arrive in the pharmacy
• fewer errors related to similar drug names
• easier to integrate with other IT systems
• easier to link to drug-drug interactions
• more likely to identify the prescriber
• available for immediate analysis
• can link to clinical decision support to recommend drugs of choice

Question 27

technologies with potential to decrease medication errors

Answer 27

• computerized provider order entry (CPOE)
• health information exchange (HIE)
• automated dispensing cabinets (ADCs)- right dose
• home electronic medication management system -> makes sure you take the medication
• pharmacy dispensing robots
• electronic medication administration record (eMAR)
• smart intravenous (IV) infusion pumps -> decimal point error
• bar coded medication administration (BCMA)
• radio frequency identification (RFID)
• medication reconciliation

Question 28

health information exchange (HIE)

Answer 28

-improve patient safety by better communication between disparate healthcare participants

Question 29

radio frequency identification (RFID)

Answer 29

• track patients, staff and inventory
• can be read-only or read-write capable
• can be read if wet or through clothing -> better for blood and IV bags
• active (needs battery, larger, more memory, longer range and more expensive)
• passive (smaller, cheaper, short range and no battery)

Question 30

medication reconciliation

Answer 30

• when patients transition form hospital to hospital from physician to physician or from floor to floor, medication errors are more likely to occur
• medications must be communicated
• must reconcile the medications -> Reduce error
• joint commission mandated hospitals must reconcile a list of patients medications on admission, transfer and discharge
• simply task with EHR -> Disparate systems that are not interoperable are found

Question 31

barriers to improving patient safety through technology

Answer 31

• organizational- health system with a culture of safety
• financial- cost of a full fledged interoperable electronic health record system
• error reporting- voluntary and inadequate / after the fact

Question 32

unintended consequences

Answer 32

• technology may reduce medical errors but created new ones
• medical alarm fatigue -> you ignore alarms if they are too frequent
• infusion pumps -> validation required
• distractions related to mobile devices
• electronic health records -> regularly assess quality, accuracy, and completeness of patient information

Question 33

goal

Answer 33

• real time data analysis to detect and/or prevent adverse patient events
• robust information technology system with a data warehouse that is assisted by evidence based rules engines