Patient Multipurpose Safety Curriculum (trans 1)

Question 1

It is a comprehensive program for effective student learning about patient safety

Answer 1

WHO Patient Safety Curriculum Guide

Question 2

REMEMBER
Fundamentals of patient safety
1. Patients can be harmed from health care
2. Adverse events occur not because people intentionally hurt patients, but rather due to the complexity of health-care systems
3. Healthcare is one of the most unsafe industries

Answer 2

** ~10% of hospital patients suffer an adverse event (AE)

Question 3

REMEMBER

Health care-associated infection (HCAI)

Answer 3

1. Hundreds of millions of patients are affected by HCAI worldwide each year
2. Of every 100 hospitalized patients at any givent time, 7 in developed and 10 in developing countries will acquire at least one HCAI

Question 4

MEDICATION ERROR is the LEADING cause of injury in developed/developing countries

Answer 4

** in some countries, 70% of patients’ medication histories (2005)

Question 5

What are the 4 Domains of Healthcare System

Answer 5

1. Those who work in healthcare
2. Those who receive healthcare or have a stake in its availability (e.g. patients and their families)
3. Infrastructure of systems for therapeutic interventions (e.g. health care delivery process)
4. Methods for feedback and continuous improvement

Question 6

True or False

There are no significant economic costs associated with unsafe care or adverse events

Answer 6

False

Question 7

What are the categories of challenges related to Unsafe Care

Answer 7

1. unsafe medical care
2. Structural factors contributing to unsafe care
3. poor processes contributing to unsafe care

Question 8

This type of culture us common for resolving problems in healthcare and is one of the main constraints in the health sytem’s ability to manage risk and improve care

Answer 8

Blame culture

Question 9

It is when individuals involved in the care at the time of incident are held accountable

Answer 9

Person approach

Question 10

It is doing the wrong thing when meaning to do the right thing

Answer 10

Error

• *errors may occur when:
  1. the wrong thing is done (commission)
  2. The correct thing is not done (omission)

Question 11

True or False

Within a skilled, experienced and well-intentioned workforce, situations are more amenable to improvement than people

Answer 11

True

Question 12

Unexpected adverse event that should never be allowed to happen; “Should never have happened” events

Answer 12

Sentinel events

Question 13

REMEMBER

Error and outcome are NOT inextricably linked

Answer 13

Harm can befall a patient in the form of a complication of care without an error having occurred

Question 14

A type of bias that occurs when the nature of the outcome usually influences our perception of the error

Answer 14

Hindsight bias

Question 15

What are the two main causes of error

Answer 15

1. Skill-based slips and lapses

2. Mistake

Question 16

REMEMBER

ERROR of EXECUTION = skill based slips and lapses

Answer 16

FAILURE of PLANNING = mistakes

Question 17

REMEMBER
skill-based and lapses
1. Slip = observable
2. Lapse = not observable (memory)

Answer 17

Mistake

1. Rule-based (e.g. misdiagnosis)
2. Knowledge-based

Question 18

It involves collecting and analyzing information about any events that could have harmed or did harm anyone in the organization

Answer 18

Incident monitoring

Question 19

In healthcare VIOLATION is a deliberate deviation from an accepted protocol or standard of care

Answer 19

Routine violations (common, often tolerated)
- Failing to practice hand hygiene because one feels he is too busy
Optimizing violations
- Senior professionals letting students perform a procedure without proper supervision because they are busy with their private patients
Necessary violations
-necessary violtions
- Time-poor nurses and doctors who knowingly skip important steps in administering (or prescribing) medication because of time constraints

Question 20

True or False

Root Cause Analysis Model (RCA model) focuses on individual performance rather than system level vulnerabilities

Answer 20

False - focused on system level vulnerabilities

Question 21

It is the beliefs, values and norms shared by the staff about what is rewarded, supported and expected

Answer 21

Patient safety culture

**It exists at multiple levels: Unit, Department, Organization, System