patient safety Flashcards
what is adverse event ?
an injury caused by medical management
what is an error ?
failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim
what is a preventable adverse event ?
ann adverse event caused by an error
what is an example of a preventable adverse event ?
anaphylaxis following administration of ampicillin
what is a near miss ?
when an error occurs but no adverse event happens
what are the reasons that serious harm did not occur in a near miss ?
chance prevention ( nurse noticed) mitigation (antidote was given)
what are the human factors associated with error ?
slips, lapses
mistakes
what are slips ?
if the action is observable
what are lapses ?
not due to an observable act but rather things as memory effects
what is the main constraint on the health systems ability to manage risk and improve care ?
blame culture
what is the most probable underlying cause behind errors ?
system failure due to complexity of health care delivery
what is the best approach to minimize error ?
follow a system based approach
what is an example of a system based approach to patient safety ?
the removal of concentrated potassium from general hospital wards
what is forcing function ?
where the system is redesigned in a way that forces an individual to avoid making the error due to process design
what does the Reasons swiss cheese model of error explain ?
cheese slices are representative of barrier and the holes are latent hazards, these holes sometimes line up and cause patient injury
what are the different barriers in the swiss cheese model of errors ?
latent factors
error producing factors
active failures
defenses
how can patient harm be avoided ?
by building systems with successive layers of protection and removal of latent errors
how can the system be redesigned to avoid death from medication allergy ?
implement a computer physician order entry (CPOE)
what are the ways of learning from an error ?
- incident reporting
2. root cause analysis
what is a sentinel event ?
an adverse event in which death or serious harm occurred to a patient, refers to events that are not at all expected or acceptable
what is root cause analysis ?
a retrospective approach
who should conduct a root cause analysis ?
knowledgeable team
what should be the main focus of root cause analysis ?
system/process analysis rather than individual performance
what are examples of for commonly used in quality improvement methods ?
- fish bone diagrams ( cause and effect diagrams)
- pareto charts
- run charts
