Lec 77: Quality and Patient Safety Flashcards
What is “quality?”
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current medical practice.
Six dimensions of quality healthcare
Safe, Timely, Effective, Efficient, Equitable (Quality does not very because of personal characteristics like gender or location), and Patient Centered
What do we mean by “patient safety”
Establishment of systems that minimize the likelihood of errors and maximize our means of intercepting errors that occur anyway.
What is medical error?
A failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
What are accidents?
The result of an accumulation of errors. An event that involves damage to a defined system that disrupts the ongoing or future output of the system
Adverse Event
An undesirable/unintended clinical outcome resulted from some diagnosis or therapy, not an underlying disease process (i.e., risk of infection after a surgery, which wouldn’t have happened if the surgery had not been performed).
Relate error to adverse event
A preventable adverse event is usually considered to fit the definition of an error.
Complex system vs. complicated system
Complex systems are systems with many parts, like complicated systems, except in complex systems, these parts have more “autonomy,” meaning they behave in unpredictable ways when interacting but their interactions are what cause an effect. With a complex system, we have sensitivity to the initial conditions and any change to these initial conditions will produce escalating and compounding errors in predictions of the system’s future behavior. (The way I interpret the take home on this difference is that with a complex system, yea it has a lot of parts, but these parts work together well. In a complicated system, you have this negative feeling because you can’t really predict any outcomes with your errors. In complex system, there is also this more interconnected web that doesn’t allow any one part to contribute or function on its own, whereas in complex system, there is a little more freedom for mistake/manipulation)
Active failures
Errors that occur at the frontline operator with almost immediately felt effects. Also termed, “sharp end” events.
Latent Conditions
Lots of small little errors along the way that may not have been attributable to one source. Also termed as precursors or preconditions that cause errors.
