Patient Safety Flashcards
Preparation for Y3S2 PR3150 Assessment
What are the NCCMERP Medication Error Categories? From A to I
A Circumstances or events that have the capacity to cause error
B An error occurred, but the medication did not reach the patient
C An error occurred that reached the patient but did not cause patient harm
D An error occurred that resulted in the need for increased patient monitoring but no patient harm
E An error occurred that resulted in the need for treatment or intervention and caused temporary patient harm
F An error occurred that resulted in initial or prolonged hospitalization and caused temporary patient harm
G An error occurred that resulted in permanent patient harm
H An error occurred that resulted in a near-death event (e.g., anaphylaxis, cardiac arrest)
I An error occurred that resulted in patient death
What are the 4 levels of harm for each NCCMERP Medication Error category?
No Error (A)
Error but no harm (B, C, D)
Error, harm (E, F, G, H)
Error, death (I)
What is harm, monitoring, intervention and intervention necessary to sustain life?
Harm = Impairment of physical, emotional, psychological function or structure of the body causing pain
Monitoring = Observe and record physiological or psychological signs
Intervention = Change in therapy or active treatment
Intervention necessary to sustain life = CPR, defibrillation, intubation (Cardio and respiratory support)
What is the difference between near misses, adverse events and adverse drug reactions?
Near-misses = Medication Errors that do not lead to harm
Adverse Events = Preventable harm resulting from both medication error and drug related problems
Adverse Drug Reaction = Non-preventable harm resulting from drug related problems alone
What are DRPs?
Indication
Adherence (Compliance)
Safety (ADR, DDI, TDM)
Efficacy (Subtherapeutic)
How do we achieve harm prevention or reduction?
Early Detection + Early Intervention
What are the 2 main paradigm shift in patient safety today?
a) Medication Safety (aka Zero Harm) => Basic Standard of Care (Expected Care)
- Patients consider “Zero Error” as “Given”, “ Basic Care”, and “Must-Have”
b) Value-based Care = What Patients Value (Person-Centred Care)
- Addressing patients’ concerns (DRP, disease-related problems)
- Improving disease-related QoL
What is Medication safety (In terms of medication use, medication therapy, patient perspective, HCP)?
▪ Freedom from unnecessary harm or potential harm associated with healthcare [medication use]
▪ Freedom from accidental injuries during the course of medical care [medication therapy]
▪ Actions undertaken by individuals and organisations to protect healthcare recipients [patients] from being harmed by the effects of healthcare services
▪ Reduction and mitigation of unsafe acts
▪ Use of best practices shown to lead to optimal patient outcomes
What is the general quality and patient safety framework in creating a safety culture?
Detection
Analysis
Improvement Strategies
Evaluate Changes
What is system thinking? What processes are involved?
Every system is perfectly designed to achieve the results that it achieves
- Inter-dependencies of systems and processes
- Impact and interactions of systems and processes
- Upstream Processes
- Downstream Processes
- Concurrent Processes
What are examples of system thinking (interactions)?
System-System interactions
▪ Clinical/IT systems, System interfaces, Medical technology, Monitoring/Diagnostic devices
System-Human interactions
▪ How healthcare staff use the system
Human-Human interactions
▪ How healthcare staff communicate with one another
What are the layers of HFACS Framework?
Organisational Influences
- Organizational Culture
- Operational Process
- Resource Management
Unsafe Supervision
- Supervision (Inadequate, Violation)
- Planned inappropriate operations
- Failure to correct known problem
Pre-conditions
- Situational factors (Tools, environment)
- Conditions of Operators (Mental, physical)
- Personnel factors (Communication, Fitness to practice)
Unsafe Acts
- Errors (Decision, Skill-based, Perceptual)
- Violations (Routine, Exceptional)
3 types of strategies to deal with patient safety issues and examples
- Proactive (Preventive)
- Enterprise Risk Management (Macro)
- Clinical Risk Management (Safety, Risk, Improvement and Innovation)
- Failure Modes and Effects Analysis (FMEA) - Reactive (Responsive)
- Incident Management
- Root Cause Analysis
- Problem Solving
- Quality Improvement Tools - On-going (Monitoring)
- Strategic Priorities
- Performance Measures
Determine the culpability of unsafe acts
Recall the Culpability Decision Tree
Principles of Questioning
1. Intention
2. Authorization
3. Error or violation
4. Substitution test
5. History of unsafe acts
Culpability
1. Sabotage
2. Substance abuse
3. Mitigation
4. Violation (Human or system induced)
5. Error (Negligence or system induced)
6. Blameless error (Consider counseling)
What is just culture?
Blame only if justified through reactive incident management strategies (Accountability)
1. Second Victim - Traumatized HCP
2. Culpability decision tree
3. Open Communication
4. Medico-legal considerations
What is open communication and why is it important?
When an error happened, patients and families experienced disappointment and anger because expected clinical care was not fulfilled
Importance:
▪ Medical Ethics – Patients’ Rights to Know
▪ Patients/Families expect Honesty, Transparency, and On-going Communications (Building Trust and Assurance)
▪ Patients/Families want to know how we prevent similar error from happening to another patient (Do we learn from it?)
What are common barriers to open disclosure?
▪ Fear (multiple reasons)
▪ Not trained in this aspect
What is the swiss cheese model?
It takes a system approach to accident investigation. With this approach, human error is viewed as a symptom of a larger problem in the organization, not the cause of the accident.
What are the two types of failures that can happen in the swiss cheese model?
- Active failure - those occurring immediately prior to an accident and directly impacting events
- Latent failure - those removed temporally from the event and not exhibiting a direct impact
