NIS document ch2 Flashcards

Question

What is practice-based learning and improvement?

Answer 1

Shows an ability to investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve the practice of medicine.

Answer 2

practice-based learning and improvement (core competency for residents)

Answer 3

patient care and procedural skills (core competency for residents)

Answer 4

Provide care that is compassionate, appropriate, and effective treatment for health problems and promote health.

Answer 5

Demonstrate awareness of and responsibility to the larger context and systems of healthcare.

Answer 6

Demonstrate knowledge about established and evolving biomedical, clinical, and cognitive sciences and their application in patient care.

Answer 7

Demonstrate skills that result in effective information exchange and teaming with patients, their families, and professional associates (e.g., fostering a therapeutic relationship that is ethically sound; using effective listening skills with nonverbal and verbal communication; and working both as a team member and, at times, as a leader).

Answer 8

Demonstrate a commitment to carrying out professional responsibilities, adhering to ethical principles, and being sensitive to diverse patient populations

Answer 9

National Academy of Sciences' Institute of Medicine

Answer 10

44,000 to 98,000

Answer 11

The report’s findings that between 44,000 and 98,000 in-hospital deaths per year were attributable to medical errors made national headlines, including a suggestion that an epidemic of death from medical errors exceeded that from motor vehicle accidents, breast cancer, or AIDS.

Answer 12

The report projected total societal costs of medical errors to be between $17 billion and $29 billion.

Answer 13

the failure of a planned action to be completed as intended the use of a wrong plan to achieve an aim, with the highest risk for errors occurring in high-acuity environments such as the ICU, OR, or ED.

Answer 14

1) the decentralized nature of the healthcare delivery system (or “nonsystem,” as the report calls it) 2) the failure of licensing systems to focus on errors 3) the impediment of the liability system to identify errors 4) the failure of third party providers to provide financial incentive to improve safety.

Answer 15

unsafe systems and processes of care. AND human error.

Answer 16

To design safety into systems and processes of care.

Answer 17

“the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.”

Answer 18

Data on diagnostic error are sparse, few reliable measures exist Often the error is identified only in retrospect.

Answer 19

A poll commissioned by the National Patient Safety Foundation in 1997 found that approximately one in six of those surveyed had experience with diagnostic error, either personally or through a close friend or relative.

Answer 20

On average, 10% of postmortem exams were associated with diagnostic errors that might have affected patient outcomes.

Answer 21

failures in communication

Answer 22

CONVEYANCE: transmission information from a sender to a receiver CONVERGENCE: verification, discussion, and clarification

Answer 23

transmission information from a sender to a receiver

Answer 24

Conveyance

Answer 25

convergence

Answer 26

verification, discussion, and clarification

Answer 27

Definition of a high reliability organization

Answer 28

organization that, despite operating in a high-stress, high-risk, complex environment, continually manages its environment mindfully, adopting a constant state of vigilance that results in the fewest number of errors.

Answer 29

ABCC: Acknowledge, blame free, collab, commitment

Answer 30

there is fear of punishment for errors, quality and safety problems are rarely reported to senior leadership. undermine the safety culture increase the difficulty of accurately measuring error rates

Answer 31

AHRQ’s Patient Safety Culture Surveys and the Safety Attitudes Questionnaire.

Answer 32

FALSE In this model, the response to an error or near miss is predicated on the type of behavior associated with the error, not the outcome or severity of the event.

Answer 33

firmly established safety norms are willfully ignored such as a physician who refuses to perform a time out before surgery, may merit firm—possibly punitive—action, even if no patients were harmed.

Answer 34

those persons who engage in at-risk behavior— e.g., workarounds of convenience, such as failing to communicate critical results, that could subvert established safety precautions—probably underestimate the risks of their actions. These persons are counseled or coached in the Just Culture Model

Answer 35

reckless behavior

Answer 36

the patient the event the processes and systems to identify opportunities for sustainable improvement. NOT the person making error as long as the individual was not acting recklessly.

Answer 37

The term “second victim” has been coined for a healthcare worker who is traumatized by an error or adverse patient event in which they were involved. These individuals often feel an intense sense of guilt, sorrow, and anxiety, and may even exhibit signs similar to post-traumatic stress disorder. Many hospitals have begun to develop internal programs to identify, console, and advocate on behalf of such individuals.

Answer 38

console innocent human error, even if this error resulted in significant patient harm, would be consoled since human errors are considered to be inevitable and not necessarily the result of negligence.

Answer 39

punishment/sanctions