Medical Errors Flashcards
What are the costs of medical errors and give examples
- Financial: extended hospital stay, more testing etc
- Psychological: they are trusting you to take care of them
- Physical: discomfort, disability, death
- Staffing: short staffed/physicians can be put on probation causing short staff
Definition of medical error
- An event that may cause harm to a patient
- An unintended injury caused by medical management that results in measurable disability
Causes of medical errors
- Schedule instability: limited practitioners causes other to have to do overtime
- Sleep deprivation
- Provider burnout: overloaded/productivity
- Workload
Types of errors and define
- omission: result of actions not taken when they should have
- commission: result of wrong action taken
Name some common medical errors
Adverse drug reactions
Catheter associated UTI
Central line infection
Pressure ulcer
Obstetric events
misdiagnosis
Venous thrombosis
Ventilator associated pneumonia
Falls
Equipment failure
Burns
Preventable suicide
Active error
The actual event that results in harm
- associated with 1st person of contact
adverse error
- an error/injury that most frequently is due to medical/surgical treatment
latent error
systems/processes design that results in an error
Medical error
Medical error: failure to do the right thing/do something knowing it could be contraindicated
negligence
Negligence: Failure to act in accordance with the standard of medical care
negligent adverse effects
Negligent adverse effects: an injury occurring during the course of medical management
near miss:
Near miss: an event that could have resulted in harm done to the patient but did not cause injury
Never event
Never event: an event that caused harm that never should have happened
noxious episode:
Noxious episode: an expected reaction to an intervention that may be uncomfortable, painful or upsetting
For basic Patient safety one should always
check devices and environment
potentially compensable event
Potentially compensable event: where there would be compensation for the event/malpractice claim
root cause
Root cause: Something that if corrected would eliminate the event from occurring
sentinel event
Sentinel event: a patient safety event that results in death, permanent harm, or severe temporary harm
How to create a safer environment? (joint commission)
joint commission has identified patient safety goals to assist facilities
ex:
- identifying patient safety dangers and risks
- confirm ID with 2 sounces
- preventing surgical mistakes
- eliminate blame/own mistakes - culture of education and prevention
- better screening and monitoring
3 general sources of health technology induced errors
- design and development
- implementation and customization
- interactions between the operation of a new technology and the new work processes
Possible causes of technology induced errors
- human factors
- sociotechnical
- organization
- software factors
Prevention of technology induced errors
- software design, development, implementation, monitoring ad maintenance
What can we as a PT do to reduce medical errors
- fill in gaps in your knowledge
- thorough screening and evaluation
- understand signficicance and relevance of PMH, medications lab results
- thorough and accurate documentation on patients
communicate clearly with patients, families, caregivers, other health care providers - be aware of safety concerns and environment
- monitor patient response to treatment
Root cause analysis
a process for identifying the causal factors underlying variations in performance
