patient safety

Question 1

what is adverse event ?

Answer 1

an injury caused by medical management

Question 2

what is an error ?

Answer 2

failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim

Question 3

what is a preventable adverse event ?

Answer 3

ann adverse event caused by an error

Question 4

what is an example of a preventable adverse event ?

Answer 4

anaphylaxis following administration of ampicillin

Question 5

what is a near miss ?

Answer 5

when an error occurs but no adverse event happens

Question 6

what are the reasons that serious harm did not occur in a near miss ?

Answer 6

chance 
prevention ( nurse noticed)
mitigation (antidote was given)

Question 7

what are the human factors associated with error ?

Answer 7

slips, lapses

mistakes

Question 8

what are slips ?

Answer 8

if the action is observable

Question 9

what are lapses ?

Answer 9

not due to an observable act but rather things as memory effects

Question 10

what is the main constraint on the health systems ability to manage risk and improve care ?

Answer 10

blame culture

Question 11

what is the most probable underlying cause behind errors ?

Answer 11

system failure due to complexity of health care delivery

Question 12

what is the best approach to minimize error ?

Answer 12

follow a system based approach

Question 13

what is an example of a system based approach to patient safety ?

Answer 13

the removal of concentrated potassium from general hospital wards

Question 14

what is forcing function ?

Answer 14

where the system is redesigned in a way that forces an individual to avoid making the error due to process design

Question 15

what does the Reasons swiss cheese model of error explain ?

Answer 15

cheese slices are representative of barrier and the holes are latent hazards, these holes sometimes line up and cause patient injury

Question 16

what are the different barriers in the swiss cheese model of errors ?

Answer 16

latent factors
error producing factors
active failures
defenses

Question 17

how can patient harm be avoided ?

Answer 17

by building systems with successive layers of protection and removal of latent errors

Question 18

how can the system be redesigned to avoid death from medication allergy ?

Answer 18

implement a computer physician order entry (CPOE)

Question 19

what are the ways of learning from an error ?

Answer 19

1. incident reporting

2. root cause analysis

Question 20

what is a sentinel event ?

Answer 20

an adverse event in which death or serious harm occurred to a patient, refers to events that are not at all expected or acceptable

Question 21

what is root cause analysis ?

Answer 21

a retrospective approach

Question 22

who should conduct a root cause analysis ?

Answer 22

knowledgeable team

Question 23

what should be the main focus of root cause analysis ?

Answer 23

system/process analysis rather than individual performance

Question 24

what are examples of for commonly used in quality improvement methods ?

Answer 24

1. fish bone diagrams ( cause and effect diagrams)
2. pareto charts
3. run charts