Lecture 25+26+DLA Flashcards
potential ADE
an error that is intercepted before reaching the patient
preventable ADE
an error that reaches the patient and causes some degree of harm
non-preventable ADE
an adverse outcome though medications are prescribed and administered appropriately
the causes of medication errors
- patient specific causes
EX: elderly taking multiple medications are more vulnerable to ADE - drug specific causes
EX: look alike or sound alike meds - clinician specific causes:
unnecessary drug prescription, transcribing errors, dosage errors, failure to identify a drug allergy
how to to reduce medication errors?
transcription training
using the 5R’s
(right drug, right patient, right does, right route, right time)
CPOE (computerized physician order entry)
how to reduce hospital-acquired infections
- hand washing- single most affective method
more sinks
more alcohol based hand rubs
no artificial nails
changing gloves
risk factors for patient falls
- over the age of 60
- taking multiple drugs (sedatives, hypnotics, antidepressants)
- impaired memory
- difficulty walking
how to reduce patient falls
- identify high risk people
- education
- safety rounds
- bed alarms
- safety companions
no-fault errors
Result from factors outside the control of the clinician or the health care system
Ex: atypical disease presentation
patient providing misleading info; uncooperative
systems-related error
The result of technical or organizational flaws
EX: inadequate communication and care coordination inefficient processes technical failure equipment issues
cognitive errors
diagnoses that are wrong, missed, or unintentionally delayed due to clinician error
Anchoring bias
A wrong diagnosis made when clinician maintains initial
impressions when making a diagnosis, and becomes
dismissive to signs and symptoms that points to another diagnosis
confirmation bias
Looking for evidence and interpretation of information to fit a preconceived diagnosis rather than the converse
Availability bias
More recent and readily available answers and solutions are preferentially favored because of ease of recall and incorrectly perceived importance
most cognitively available diagnosis
Diagnosis Momentum
When the diagnosis considered by one clinician becomes the definitive diagnosis as it passed from one clinician to the next; it then becomes accepted without
question by clinicians down the line
framing effect
Diagnostic decision-making unduly biased by extraneous and collateral information
slips (medical error)
Actions not carried out as intended or planned
Ex: giving an iv injection instead of subcutaneous
lapses (medical error)
missed actions and omissions
ex: forgetting to monitor a patient and replacing serum K in a patient with AHF
Mistakes (medical error)
A wrong intended action
e.g., a faulty plan or incorrect intention
violation
not a type of medical error
Deliberate actions whereby someone does something and knows it to be against the
rules
EX: deliberately failing to follow proper procedures
near-miss (outcome of medical error)
Errors that occur but do not result in injury or harm to patients because they are caught in time or simply because of luck
adverse events (outcomes of medical errors)
Harm or injury that results directly from the management of a patients’ disease or condition by health care professionals rather than by the underlying disease or condition itself
Sentinel event (outcome of medical error)
Adverse event in which death, permanent or severe temporary harm to a patient has occurred; used to refer to events that were not at all expected or acceptable
Never Event / Serious Reportable Events (outcome of medical error)
adverse events in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility
Ex: surgical events product events care management events potential crime event
Factors that contribute to Unsafe Care
communication and teamwork failure errors at hand off stress and fatigue poor working conditions lack of education
what mediates signaling in B cell receptors?
Ig alpha and Ig beta
BCR’s are antibodies
the light chain
The amino (N) terminal domain is variable and the site of antigen binding
the constant domain at the carboxy terminal; it can be kappa or lambda
The heavy chain
this chain determines the 5 classes of Ig: G, A, M, E, and D
Constant region (C): nearly invariant; not involved in antigen binding
IgG
monomer, produced by plasma cells (primary
response) and memory cells (secondary), most prevalent
2 binding sites
most common in serum
can cross placenta
binds to phagocytes
long term immunity
memory Ab’s
neutralizes toxins and viruses
IgA
2 or 4 binding sites
does not cross placenta
binds to epithelial cells
secretory Ab on mucous membranes
IgM
10 binding sites
does not cross placenta
first to be produced in response to antigen
can serve as a B cell receptor
IgD
2 binding sites
does not cross placenta
receptor on B cells for antigen recognition
IgE
2 binding sites
does not cross placenta
binds to mast cells and basophils
the antibody of allergy; worm infections
T cell receptor
heterodimer recognizes peptides displayed by MHC
molecules
composed of an alpha and beta chain
each with a V and C region
do not undergo class switching
TCR complex
it can recognize the antigen but does not transmit signals
complex with 3 dimers
associated with CD3
needs a coreceptor (CD 4 or 8)
Lymphopoiesis
B cell production occurs throughout life; does not
wane as does T cell production
process in which lymphocytes develop from progenitor cells
B cell development
the goal is to produce plasma and memory cells
- antigen-independent phase (bone marrow)
- antigen-dependent phase
- Differentiation of active B cells into plasma and
memory cells
antigen independent phase of B cell development
pro B cells: expression of CD45R and CD 19 IL 7 supports this process successful re-arrangement of the ig heavy chain = pre-B cells Tdt catalyzes the heavy chain coding
pre-B cells:
seen to have igu heavy chain in cyto
induce recombination of ig light chains
BTK
Bruton’s tyrosine kinase (BTK) is a kinase that plays a
crucial role in B-cell development
Mutations in the BTK gene are implicated in the primary
immunodeficiency disease: X-linked agammaglobulinemia (XLA)
the pre-B cells fail to mature
BTK inhibitors are used in the treatment of some cancers and autoimmune diseases
immature B cells
IgM is expressed on the surface
negative selection occurs (clonal deletion)
functional B cell receptor appears
mature B cell expresses?
IgM and IgD
involves a change in RNA processing of the heavy chain
naive B cells
migrate out of the bone marrow
no dividing
no antigen encounter
negative selection; thymocyte
Elimination of any CD4 or CD8 cells that have
high affinity to selfMHC alone or to self MHC-self epitope complexes
these cells are programmed to die
ensures self-tolerance
AIRE
autoimmune regulator; transcription factor expressed in the medulla of the thymus
drives negative selection of T cells ( so body does not attack itself)
when AIRE is defective it can lead to autoimmune disease
