Patient Multipurpose Safety Curriculum (trans 1) Flashcards
It is a comprehensive program for effective student learning about patient safety
WHO Patient Safety Curriculum Guide
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
** ~10% of hospital patients suffer an adverse event (AE)
REMEMBER
Health care-associated infection (HCAI)
- Hundreds of millions of patients are affected by HCAI worldwide each year
- Of every 100 hospitalized patients at any givent time, 7 in developed and 10 in developing countries will acquire at least one HCAI
MEDICATION ERROR is the LEADING cause of injury in developed/developing countries
** in some countries, 70% of patients’ medication histories (2005)
What are the 4 Domains of Healthcare System
- Those who work in healthcare
- Those who receive healthcare or have a stake in its availability (e.g. patients and their families)
- Infrastructure of systems for therapeutic interventions (e.g. health care delivery process)
- Methods for feedback and continuous improvement
True or False
There are no significant economic costs associated with unsafe care or adverse events
False
What are the categories of challenges related to Unsafe Care
- unsafe medical care
- Structural factors contributing to unsafe care
- poor processes contributing to unsafe care
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
Blame culture
It is when individuals involved in the care at the time of incident are held accountable
Person approach
It is doing the wrong thing when meaning to do the right thing
Error
- *errors may occur when:
1. the wrong thing is done (commission)
2. The correct thing is not done (omission)
True or False
Within a skilled, experienced and well-intentioned workforce, situations are more amenable to improvement than people
True
Unexpected adverse event that should never be allowed to happen; “Should never have happened” events
Sentinel events
REMEMBER
Error and outcome are NOT inextricably linked
Harm can befall a patient in the form of a complication of care without an error having occurred
A type of bias that occurs when the nature of the outcome usually influences our perception of the error
Hindsight bias
What are the two main causes of error
- Skill-based slips and lapses
2. Mistake
REMEMBER
ERROR of EXECUTION = skill based slips and lapses
FAILURE of PLANNING = mistakes
REMEMBER
skill-based and lapses
1. Slip = observable
2. Lapse = not observable (memory)
Mistake
- Rule-based (e.g. misdiagnosis)
- Knowledge-based
It involves collecting and analyzing information about any events that could have harmed or did harm anyone in the organization
Incident monitoring
In healthcare VIOLATION is a deliberate deviation from an accepted protocol or standard of care
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
True or False
Root Cause Analysis Model (RCA model) focuses on individual performance rather than system level vulnerabilities
False - focused on system level vulnerabilities
It is the beliefs, values and norms shared by the staff about what is rewarded, supported and expected
Patient safety culture
**It exists at multiple levels: Unit, Department, Organization, System
