Mod. 5 Patient Safety Flashcards
Who developed the National Patient Safety Goals?
TJC
What does the National Quality Forum (NQF) do?
Sets voluntary consensus standards. With support of Robert Wood foundation, set 34 safety practices that reduce harm if implemented
What is the Agency for Healthcare Research and Quality (AHRQ)
Lead federal agency charged with improving quality and safety of US healthcare system
What is a tenet of Just Culture?
Everyone makes mistakes and emphasizes the importance of learning from mistakes and near misses
What is the greatest error in Just Culture?
Not reporting a mistake (it prevents learning)
How do you create a Just Culture?
When everyone advocates for safety
At its core, patient safety is about…
ensuring patients are treated in a safe environment and eliminating errors
What are HAIs?
Healthcare associated infections
What are some approaches to improving patient safety?
Improve:
- Medication practices
- Emerging services
- Workplace safety
Reduce:
-Healthcare Associated Infections
Involve:
Patient/family
What are the two types of errors?
- Omission: not doing what you’re supposed to
- Commission: doing it in error
What is under use of care?
Patients don’t receive beneficial services (flu shots not given)
What is over use of care?
Patients receive treatment without benefit (antibiotics for a cold)
What is misuse of care?
Patients receive appropriate but poorly provided services, exposing them to added risk of preventable complications (prescribing medication when patient is allergic)
What is the National Committee for Quality Assurance’s (NCQA) measurement system
Healthcare Effectiveness Data and Information Set (HEDIS)
What is HEDIS used to measure?
Data sets that are targeted toward health plans, wellness and health promotion and disease management programs
What is a sentinel event?
Adverse outcome identified that involves a death or serious physical or psychological injury
Why is it important to share close call events?
Occur 300 times more than actual adverse events so provide an accurate picture of what actually occurs so you can learn/develop strategies
What is a failure mode and effects analysis (FMEA)?
A way for staff to be proactive in their pursuit of quality and safety versus to being reactive; to imagine what could go wrong and correct any risk factors before errors occur.
What does a failure mode and effects analysis (FMEA) include?
- Steps in the process
- Failure modes (what could go wrong)
- Failure causes (why would the failure happen)
- Failure effects (what would be the consequences of each failure)
How do you construct a failure mode and effect analysis (FMEA or HFMEA for healthcare failure mode and effect analysis)?
- Define the topic and process to be studied
- Convene an interdisciplinary team with content and process experts
- Develop a flow diagram of the process with consecutive numbering of each step and lettering of all sub processes
- List all possible failure modes of each sub process, including the severity and probability of the failure mode, and then number these failure modes (brainstorming may be helpful to id failure modes)
- After analyzing the failure modes, determine the action for each failure mode to eliminate, control or accept
- Identify the corresponding outcome measure to test the redesigned process
What is an root cause analysis (RCA)
Analysis to determine the cause of a variation in a process. Human, environmental, equipment, policy and leadership system factors are explored in the analysis
What are the steps in an RCA once an event has occured?
- Risk based prioritization
- Ask what happened? Fact finding and flow diagramming
- Development of causal statements
- Identification of solutions and corrective actions
- Implementation
- Measurement
- Feedback
Which step of the RCA should take place within 72 hours?
Risk-based prioritization (starting process)
Which steps of the RCA process should take place within 30-45 days
Fact finding, causal statements, identification of solutions
A root cause analysis is required by several accrediting organizations in response to a sentinel event. True or False?
True
What is risk management?
The process of making and carrying out decisions that will minimize the adverse effects of accidental losses
What is the goal of risk?
Protect the organization from financial loss which may be due to risks
Enterprise risk management (integrated across entire organization) has the goal of…
Reducing uncertainty and process variability, promoting patient safety
