Medical Errors Flashcards
What accounts for many necessary patient deaths, expenses, and loss of physician trust?
Medical errors
What is a medical error?
The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim
What are some examples of medical errors?
- Adverse drug evens
- Improper transfusions
- Surgical injuries
- Wrong-site surgery
- Suicides
- Restraint-related injuries or death
- Falls
- Burns
- Pressure ulcers
- Mistaken patient identities
What are the 4 types of medical errors?
- Diagnostic
- Treatment
- Preventive
- Other
What is error/delay in diagnosis, failure to employ indicated tests, use of outmoded tests or therapy, and failure to act on results of monitoring or testing examples of?
Diagnostic medical errors
What are 5 examples of treatment medical errors?
- Error in the performance of an operation, procedure, or test
- Error in administering the treatment
- Error in the dose or method using a drug
- Avoidable delay in treatment or in responding to an abnormal test
- Inappropriate (not indicated) care
What is failure to provide prophylactic treatment and inadequate monitoring or follow-up of treatment examples of?
Preventive medical errors
What are 3 other examples of medical errors?
- Failure of communication
- Equipment failure
- Other system failure
What are medical mistakes commonly caused by?
Faulty systems, processes and conditions that lead people to make mistakes or fail to prevent them
True or False: Medical errors do not result from individual recklessness or the actions of a particular group
TRUE
How can medical errors be prevented?
By designing the health system at all levels to make it safer and make it harder for things to be done wrong
What are 4 strategies established for improvement of medical errors?
- Establishing a national focus to create leadership, research, tools, & protocols to enhance the knowledge base about safety
- Identifying & learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems
- Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care
- Implementing safety systems in health care organizations to ensure safe practices at the delivery level
What was created to establish a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety?
The center for patient safety which is a single agency to set goals, track progress, and do research
What type of reporting systems are used for hospitals and all health care organizations for serious injury?
Mandatory
What type of reporting systems are used for broader sets of errors?
Voluntary
What demands safety?
- Culture of safety
2. Leaders in the workforce
What are 3 examples of stakeholders involved in reducing medical errors?
- Hospital associations
- Professional associations
- Accrediting bodies
Who is the 1st stakeholder involved in reducing medical errors and why?
The Federal Government- They are allocated money for safety research
Funding through the federal government allowed research in what?
Error prevention
What has become the leader in education, training, conveying agenda setting workshops, disseminating information, developing measures, and facilitating the settings of standard?
The AHRQ established center for quality improvement and safety
What administration is involved with the implementation of safe practices, training programs, and the establishment of 4 patient-safety research centers?
Veterans health administration
Who requires hospitals to implement new safe practices?
Joint Commission of accreditation of healthcare organizations
What is the public-private partnership to develop and approve measures of quality of care, develop a consensus process that generated standards for mandatory reporting and created a list of high impact evidence-based safe practices?
NFQ
What did the CDC and centers for Medicare and Medicaid Services do?
Reduce surgical complications
What has the American college of physicians incorporated into their meetings, education, and research?
Safety topics
True or False: The National patient safety foundation is a major force in increasing awareness, but doesn’t have much funding
TRUE
Who engaged in a massive effort to define competencies and measures in each specialty, both for residency training and continuing evaluation or practicing physicians?
The accreditation council on graduate medical education and American board of medical specialties
Who helped hospitals redesign their systems for safety through demonstration projects, system changes, and training in implementation of safe practices?
The institute for healthcare improvement
Why is the overall impact of attempts to improve patient safety hard to see in nationwide statistics?
No comprehensive nationwide monitorying system
Do critics view safety as a science?
NO
Who does the public fix blame on and who should they fix blame on?
They fix blame on bad physicians instead of improving problems of the bad systems
What are 2 issues concerning complexity that are barriers to attempts to improve patient safety?
- Medical technology is more complex than technology in other industries
- Relationships between different people are more complex- There are many specialties and types of medical professionals
Because of medicine’s commitment to individual professional autonomy, what kind of approach should we use to reduce medical error?
A nonblame systems oriented approach
How did physicians react to the high mortality data in the IOM report?
With disbelief and concern that it would undermine public trust
What are 4 things concerning fear that are barriers to improving patient safety?
- Fear of loss of autonomy
- Antipathy towards attempts by those outside medicine to enact changes
- Skepticism about the systems approach
- Fear of malpractice liability
Where is there a lack of leadership that is a barrier to improving patient safety?
Hospital and health plan level
Why is puacity of measures a barrier to improving patient safety?
Because it takes time to ID problems and show results of changes
What are 2 ways in which reimbursement structure rewards less safe care?
- Insurance companies won’t pay for new practices that decrease errors
- Payers often subsidize unsafe care unknowingly- Physician and hospital bills patient for additional services needed to fix the mistake
Who made the report To Err is Human?
The institute of Medicine (IOM)
What did the IOM make people aware of?
- Medical error problems and the morbidity/mortality it causes
- That errors are caused by bad systems, not bad physicians
JCAHO required hospitals to implement how many of the safe practices of the 30 NQF published in 2003?
11
What did teaching hospitals do in 2003 to prevent errors made by fatigue?
Reduced the number of hours residents worked
What will improve communication?
Electronic health records
Who is trying to push the idea of electronic health records into more offices around the nation?
The department of health and human services
Who has given much interest to implementing the NQF safe practices?
JCAHO and centers for medicare and medicaid services
What are the ACGME articulated as 2 of the core professional skills included in residency programs?
Practice based learning and systems based practice
How should training physicians, nurses, and other professionals work?
As a team
What is a big way to alter the healthcare arena for patient safety?
Enlisting the support of stakeholders
How much did the US congress give for patient safety research?
50 million
Who was given the money from the federal government in 2004 for information technology studies?
Agency for healthcare research and quality (AHRQ)
Who opened a center for quality improvement and safety?
Agency for healthcare research and quality (AHRQ)
What did the Veteran’s Health Administration do to reduce medical errors?
Enacted systems wide safe practices, training programs, and patient-safety research centers
Who required hospitals to implement safe practices?
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Who developed standards for mandatory reporting and list of high impact safe practices?
National Quality Forum (NQF)
What did the Centers for Medicare and Medicaid Services and the CDC do?
They joined other surgical organizations in a program to reduce surgery complications
What does the National Patient Safety Foundation do?
Increases awareness
Who helped hospitals redesign systems?
Institute for healthcare improvement
Who helps groups work together?
Regional Coalitions
Purchasers and Payers, especially with Leapfrog Group, encourages hospitals to adopt what?
Safety practives
Who is more alert to safety hazards and making changes?
Physicians, nurses, therapists, and pharmacists
List the major stakeholders involved in reducing medical errors? (10)
- Federal government
- Veteran’s Health Administraion
- Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
- National Quality Forum (NQF)
- Centers for Medicare and Medicaid Services and CDC
- National Patient Safety Foundation
- Institute for Healthcare Improvement
- Regional Coalitions
- Purchasers and Payers (Leapfrog Group)
- Physicians, nurses, therapists, and pharmacists
What is happening to changing of practices to make health care safer?
It’s accelerating
Who requires hospitals to adopt certain changes that used to be voluntary and give 1 example?
JCAHO
-Teaching hospitals adopted residency training work hour limitations
Who has the federal government appointed to oversee the dissemination of electronic health records?
Dr. David Brailer in the Department of Health and Human Services
What do physicians experience when disclosing a mistake made?
Resolution of anxiety and guilt
True or False: Full disclosure has a big effect on the likelihood that an injured patient will seek legal counsel
FALSE… it has little effect
What can successful disclosure of a medical error do?
Improve a patients confidence in the physician and lead to improved outcomes
When is a patient more likely to seek legal counsel?
When there are more serious consequences for the error
Sharing in the error even if you believe it was caused by someone else does what?
Helps the team feel supported by each other and their leaders
Sharing the error allows the team to talk about what?
Making changes
What is the only preventative medicine we can offer against future errors?
Acknowledging errors when they occur and disclosing them fully
True or False: Patients prefer detailed disclosure about what happened, why it happened, the consequences, and strategies for preventing future errors
TRUE
What are 3 things patients might desire when a medical error occurs?
- Provide appropriate care
- Adjust the response to the severity of the error
- Consider financing compensation
