Introduction to Patient Safety Flashcards
Right to Respect and Dignity
Patient safety is based on the right to respect and dignity.
- Healthcare professionals have an obligation to treat all clients with respect and dignity.
What study provided a benchmark for patient safety?
Baker and Norton undertook a study in 2004 to determine the extent of medical errors in Canadian hospitals which included 20 hospitals in 5 provinces.
What is needed to create patient safety culture?
Change in culture requires a change in mindset… a shift from the blame culture to the patient safety culture.
What is one of the most important factors in ensuring a culture of safety and transparency?
To create a culture that ensures patient safety, leaders must demonstrate commitment through articulated values and actions.
There should be a greater focus on system issues, rather than on individual blame, and recognition that failed processes may contribute to errors.
Definition of harm.
An outcome that negatively affects a patient’s health and/or quality of life.
Disclosure of Error
Disclosure is the process by which health care professionals communicate and adverse event to the patient.
The disclosure process needs to be open and transparent.
RNAO Position Statement on Patient Safety
RNAO believes that in spite of challenging work environments, action can be taken to provide an environment that supports excellence and consequently, a safe environment for patients and caregivers.
Recommendations of RNAO:
- Amend legislation to have senior nurse administrator in all sectors responsible for nursing practice.
- Introduce whistle blower protection at the provincial level to enable health care providers to speak out when safety is being compromised.
- Create a blame free organizational culture.
- Promote collaborative team practice in work settings.
What is the Patient Safety Culture “Bundle”?
Encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behaviour, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication, and industry-wide standardization/alignment.
Canadian Incident Analysis Framework
- Before the incident.
- Immediate response.
- Prepare for analysis.
- Analysis process.
- Follow through.
- Close the loop.
How often does patient harm happen in Canadian hospitals?
In 2018-2019, 1 in 18 hospital stays in Canada involved at least one harmful event (a total of 132,000 out of 2.5 million hospital stays).
What are the 4 categories of harmful events?
- Health care and medications (like bed sores or getting the wrong medication).
- Infections (like surgical site infections).
- Procedure-related (like bleeding after surgery).
- Patient accidents (like falls).
