Medical Errors Flashcards
ISO DEFINITION OF QUALITY
internation standards of
“the degree to which a set of inherent characteristics fulfils requirements”
DEFINING QUALITY OF CARE
Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with the current professional knowledge
-IOM 1990
Whether individuals can access the health structures and processes of care which they need and whether the care is effective
- Campbell et al. 2000
domains in quality care!!!!!!
safety, efficiency, access, patient centered, equitable, effectiveness!!!!!!!
MEDICAL ERROR!!!v short answer questino
Failure of a planned action to be completed as intended or the use of wrong plan to achieve an aim
ADVERSE EVENT
An undesired outcome resulting from medical management rather than underlying condition of the patient
negligence
Failure in meeting the expected standards of care by an average qualified physician
PATIENT SAFETY
Freedom from accidental injury
Medical errors cause between
44,000 – 98,000 hospital deaths in US per year
what are the chances of making mistakes
It must be accepted that human errors will occur at a level of between 1/1000 and 1/5000 events, and that this will increase in stressful situations.
CHARACTERISTICS OF AN ERROR
Non-random and recurrent pattern
Circumstances and not practitioners influence error
Directly dependent on error provoking factors within the system
A majority attributable to system and structural deficiencies
system errors
Flaws in the systems and processes that contribute to most mistakes environmental factors (fatiguesWorkload - Equipment - Physical agents
organizational model:ORGANIZATION - Management Decision/Policies - Communication -Hierarchy - Inadequate Motivations
stages of errors in clinical lab
pre analytical (46-68%
analytical 7-13.3%
post analytical 18.5-47
why not disclose the rror
Error is trivial
Error does not cause harm
Patient is ignorant about the concept of error
May impair the patient’s trust in the physician
May increase emotional liability
Patient DisclosureThe Who’s, When’s and What’s
The individual most appropriate to handle the discussion as identified by the concurrence of the team
May be a doctor, nurse, manager, social worker, allied health care professional
Largely situation specific
As a general rule, disclosure should be made as promptly as possible, and as appropriate given the patients medical and emotional condition
Disclosure is a process- avoid speculating and state what is known at the time
Nature, severity and cause of the unanticipated outcome presented in a non-judgmental manner
Expression of regret about the unanticipated injury or result
Educate the patient and/ or patient family about the clinical implications of the unanticipated outcome and future plans
failur to disclose
Broken Trust- Mutual respect and trust patients expect from their provider suffers
Ethical Challenge- Undermines the primary responsibility of the provider to their patient
Financial Factor- May increase the likelihood of a lawsuit and increase the punitive damage award
