L26, L28, L29, L30- Healthcare & Patient Care Flashcards
(47 cards)
about how many people will be harmed while receiving health care
1 in 10: 43 mil worldwide per yr, 8th leading cause of wrongful death in the US
list the common adverse patient effects
1) medication errors
2) HAIs (hospital acquired infections)
3) pt falls in hospital (1/3 of Pts > 65)
4) unplanned readmission
5) surgical/anesthesia errors
6) unsafe injection practices
7) unsafe blood products
describe common causes of medication errors
- poor handwriting
- incorrect dosing or route of administration
- look-alike drugs
describe the prevalence of HAIs
- 5-15% of all hospitalized Pts
- 40% ICU Pts
- 40% catheter Pts (UTIs)
- 70% central line Pts (blood infection)
- HAP (hospital acquired pneumonia)- 2nd most common nosocomial infection
- SSI (surgical site infection)
what are the three factors that contribute to unsafe care
- structural
- human
- process
describe the structural factors that contribute to unsafe care
- lack of structural accountability
- non-existent safety culture
- lack of training, education of human resources
describe the human factors that contribute to unsafe care
- communication/teamwork failure
- errors at transition times
- stress, fatigue
- poor working conditions
describe process factors that contribute to unsafe care
- misdiagnosis
- poor test f/u
- counterfeit/substandard drugs
- no teamwork training
list the types of medical errors
-slips
-lapses
-mistakes
(-violations)
define slip
action not carried out as intended/planned
define lapses
missed actions/omissions
define mistakes
wrong intended action (faulty plan, incorrect intention)
define violation
deliberate action, known to be against the rules (failing to follow proper procedures)
NOT AN ERROR
list the outcomes of errors
1) adverse event
2) near-misses
3) sentinel event
( 4) violation)
define adverse event
harm/injury resulting directly from management of disease by provider, rather than underlying disease
define near-misses
errors that occur, but do not result in injury or harm to Pts b/c caught in time or by luck
define sentinel event
adverse event with death or detrimental harm occurs
list the diagnostic errors
- No-fault: happens when there are masked or unusual Sxs of disease, or if Pt is not fully cooperative
- Systems-related: technical/equipment failure, organizational flaws
- Cognitive errors: wrong, missed, delayed Dx due to clinician error
list the common cognitive errors
- Anchoring bias: wrong Dx due to clinician holding onto particular Dx (dismisses other Sxs pointing to alt. Dx)
- Confirmation bias: evidence to support pre-conceived opinion rather than evidence that refutes (or greater support to other Dx)
- Availability bias: assuming Dx based on recent Pt encounters or memorable cases
define safety culture
- environment where everyone can bring up errors freely
- facilitates error identification
- data collected for internal and external monitoring
differentiate the two types of medical errors in Reason’s ‘swiss cheese’ metaphor
Active factors: mistakes, procedural violations –> immediate impact
Latent factors: faulty equipment, lack of training –> accident waiting to occur
describe Human Factors (Ergonomic) Design
- Forcing functions: prevent undesirable actions
- Standardization: improves reliability; guidelines/checklists
- Simplification: reduce wasteful activities
what are the methods of analysis of medical errors
1) Root Cause Analysis: retrospective, how did it happen (not whose fault)
2) Failure Mode and Effects Analysis: forward looking approach
describe a PDSA
Plan-Do-Study-Act Cycle: continuous, on-going, rapid evaluation of safety procedures with incremental changes always occurring
