Patient Safety

Question 1

how does the Canadian Patient Safety Institute (CPSI) define general patient safety?

Answer 1

“the pursuit of the reduction and mitigation of unsafe acts within the healthcare system, as well as the use of best practices shown to lead to optimal patient outcomes.”

Question 2

what are the three key elements associated with patient safety that are needed to be understood?

Answer 2

1. types of errors
2. placements of errors
3. ways of building a culture of safety

Question 3

the placement of errors may be described as active or latent. what are active errors (“sharp end”)? provide examples.

Answer 3

active errors are made by workers who are providing patient care, responding to patient needs.

ex: medication errors, falls – anything that directly affects the patient.

Question 4

the placement of errors may be described as active or latent. what are latent errors (“blunt end”)? provide examples.

Answer 4

latent errors are more organizational or design-related. a latent error is a flaw in a system that does not immediately lead to an accident, but establishes a situation in which a triggering event may lead to an error.

ex: poor setup of a room, lack of policy for preparation

Question 5

name the four categories of harmful events and their percentage.

Answer 5

37% health care and medications
37% infections
23% procedure-related
3% patient accidents

Question 6

how can we prevent incidents (falls, sips, procedure-related, etc)?

Answer 6

analyze data, finding the root cause of these events/incidents. it is very important to identify the root causes and teaching students about them.

report incidents! identify risk factors

Question 7

define safety in terms of nursing care.

Answer 7

decreasing risks of dangers or hazards to prevent accidents, injuries, mistakes, & harm.

Question 8

define safety in terms of nursing care.

Answer 8

requires everyone in a facility to engage in safe behaviours, be aware of surroundings to protect against unsafe situations, prevent safety hazards.

Question 9

define attributes of safety, and list at least 2 attributes of professional nurses regarding safety and patient care.

Answer 9

attributes of safety: precautions taken to be safe and to prevent adverse occurrences.

ex: nurses should be knowledgeable related to the safety of the patient and to enhance such safety; competency; acknowledge mistakes; take precautions to be safe and to avoid adverse effects; reporting incidents

Question 10

what are alterations to safety, and what do they result in?

Answer 10

alterations to safety includes incomplete assessments, skipping a step during a procedure, or even unintentional mistakes.

these can result in longer hospital stays, accidents, injuries, infections, functional decline, death.

Question 11

what is: STOP! Clean Your Hands Day

Answer 11

a national campaign that encourages healthcare workers/volunteers, patients and their families, and members of the public, to clean their hands to prevent the spread of infection.

Question 12

what are the ‘4 Moments for Hand Hygiene’?

Answer 12

• BEFORE contact with the patient or patient environment
• BEFORE a clean/aseptic procedure
• AFTER contact with blood or body fluids
• AFTER contact with the patient or patient environment

Question 13

what is: PJ Paralysis

Answer 13

a term to describe the negative physical and psychological effects experienced by patients who spend lengthy periods of time inactive, and in their pyjamas while in hospital.

if patients stay in their pyjamas or longer than they need to, they have a higher risk of infection, loss of mobility, fitness and strength, and will ultimately stay longer in the hospital.

If we can help patients get back to their normal routine as quickly as possible, including getting up and out of bed, this will mean a quicker recovery.

The idea is that by encouraging long-term patients to change out of hospital gowns and into personal garments on a daily basis, their health outcomes will be improved.

Question 14

what is: The Best Possible Medication History (BPMH) form

Answer 14

a form that is pre-populated with dispensed prescriptions recorded in the Pharmaceutical Information Network, and can be used to complete the BPMH, admission orders and retained as permanent part of the chart.

an accurate list of all of a patient’s prescribed medications, non-prescription and OTC drugs, supplements and herbal remedies, is collected and communicated to other healthcare professionals as they become involved in the care of the patient.

Question 15

healthcare facilities can use three-pronged approach to quality and safety. what are the three approaches?

Answer 15

1. organization’s support for keeping quality in safety a priority (promoting safety culture)
2. healthcare employees consistently choosing to follow health safety rules and standards
3. encouraging patients to be actively engaged in every aspect of their care

Question 16

what are diagnostic errors?

Answer 16

result of a delay in diagnosis, failure to employ indicated tests, or failure to act on results of monitoring or testing.

wrong diagnosis / inadequate information, not sending patients for tests, using outdated or old versions of tests, etc.

Question 17

what are treatment errors?

Answer 17

occur in the performance of an operation, procedure, or test; in administering a treatment; in the dose or method of administering a drug; or in avoidable delay in treatment.

Question 18

what are preventative errors?

Answer 18

occur when there are failures to provide prophylactic treatment and inadequate monitoring or follow-up of treatment.

omitting referral to OT/PT, not turning a patient every 2-4 hours to avoid bed sores, etc.

Question 19

what are communication errors?

Answer 19

lack of communication or clarity in communication. can lead to many types of errors.

not sharing tests results or action plan with team, omitting pertinent details in progress notes, poor handover during break or end of shift, etc.

Question 20

independent interventions include?

Answer 20

standard precautions such as proper hand hygiene, use of protective equipment, safe injection practices, etc.

independent interventions are those which do not require orders and/or are mandated by policies.

Question 21

collaborative interventions include?

Answer 21

developing a culture of safety; blame-free environment; focus on systems, not individuals.

collaborative procedures focus on how the system should be changed to enhance safety.

Question 22

what is “Just Culture”?

Answer 22

seeks to find a balance between the need to learn from mistakes and the need for disciplinary action against employees.

Question 23

explain Reason’s Swiss Cheese Model of Accident Causation.

Answer 23

Each cheese represents a barrier put in place to try to make the health care system safer. Each safeguard inherently contains a number of weaknesses, which are represented by the holes in the cheese. The holes in the slices of cheese are continuously moving around and often a subsequent barrier is able to stop a hazard from reaching the patient, but when the holes line up in certain combinations, hazards have the opportunity to sneak through the safeguards that have been put in place and find their way to the patient. The holes at the end of the system, which come into contact with the patient, are termed active failures and generally involve those directly involved in patient care (e.g., nurses, physicians).