Patient Safety Flashcards
What are the patient safety events related to infection prevention
Stage III and IV pressure ulcers
Burn
CAUTI
CLABSI
SSI
What are the worst patient safety events?;
Sentinel events
Examples of less severe incidents in patient safety
Mild allergic reaction
Minor delay
Examples of sentinel events
Wrong site surgery
Example of serious adverse event
Fall with fracture
Cause significant harm or even death and are unrelated to the natural progression of a patient’s illness
Sentinel events
What is required after a sentinel event?
Root cause analysis
Potential or realized significant harm events in healthcare
Serious adverse outcome
Is a root cause analysis requires for a serious adverse outcome?
No
Systematic approach to enhancing patient safety through categorized safety events
Patient safety event taxonomy (PSET);
What should drive decision making in PSET?
Data
What are the categories if PSET
Impact
Type
Domain
Cause
Prevention and mitigation
Category of PSET that offers insights into tangible outcomes, such as patient harm resulting from medical errors or systemic issues
Impact
Category of PSET that illustrated the core of the incident, shedding light on processes that may have gone wrong
Type
What is the PSET category that adds context, considering personnel and settings involved.
Domain
What is the PSET category that offers an analytical perspective moving forward, uncovering underlying factors and agents contributing to the adverse event
Cause
What PSET category measures how to reduce future occurrences
Prevention and mitgation
Purpose of public reporting of adverse events
Public accountability for providers, informed consumer choices, supporting quality improvement
What are the parts of creating a culture of safety?
Risk and incident reporting
Provider responsibility
Harm stratification
Accreditation protocols
Infection preventiionist expertise
Creating a culture of safety: describe risk and incident reporting
Importance of transparency in revealing system defects
Creating a culture of safety: describe provider responsibility
Vital role of individual providers in surveillance
Creating a culture of safety: describe harm stratificarion
Prioritizing incidents through harm scores
Creating a culture of safety: describe accreditation protocols
Mandated organizations like the joint commission for systematic responses
Creating a culture of safety: describe infection preventionist expertise
Unique skillet IPs bring for enhanced patient safety
Examples of harrnessing patient safety science for effective interventions
Human factors engineering
Humans factor analysis
Error wisdom
Reliability science
Root cause analysis
Failure mode effective analysis
Describe human factor engineering
- aligns design with human attributes
- used centered tools to enhance compliance and reduce errors
- collaboration with end-users
Proactive patient safety intervention with goal to create systems and tools that are intuitive, efficient, and safe for human use
Human factor engineering
Describe human factor analyses
- reactive
- investigating and understanding the role of human factors in instance, accidents, or errors that occur within systems
What model is typically used for human factor analysis
Systems engineering initiatives for patient safety (SIEPS)
Describe error wisdom
HCP, regardless of expertise, susceptible to errors
Three main categories of error wisdom
Skill based
Rule based
Knowledge based
Errors that occur when individuals make mistakes during routine or habitual task often due to slips or momentary lapses in attention
Skill based errors
Errors that happen when individuals make decisions based on established rules, guidelines, or standard operating procedures, but these rules do not align with the specific situation they encounter
Rule based errors
Errors that occur when individuals make errors of judgment or decision making often because they lack complete or accurate information about a particular situation
Knowledge-based errors
Example of how to address error wisdom
- checklists
The accumulation of task in healthcare can increase the cognitive workload, elevating the risk of errors
Cognitive stacking
Example of a model of error
Swiss cheese model
Failure free operation over time
Reliability
What are the attributes of high reliability organizations?
- preoccupation with failure
- sensitivity to operations
- reluctance to simplify
- commitment to resilience
- deference to expertise
Through examination that uncovers the fundamental issue behind problems. It involves the retrospective analysis of adverse outcomes, aiming to unearth the underlying causes behind incidents, and ultimately, it directs efforts towards system redesign for enhanced safety
Root cause analysis
Describe the root cause analysis
- Multidisciplinary teams
- Structured interviews and document reviews
- tools like the fishbone diagram
Proactive model to predict and prevent failures before they happen.
Failure mode effect analysis (FEMA)
Steps for failure mode effect analysis
1) identify high risk processes
2) use flow diagrams to pinpoint potential failure points
3) assigned severity and probability for each potential point of failure
Gram negative diplococci
Neisseria meningitidis
Part of bacteria for sex
Pili
Part of bacteria to adhere to surfaces
fimbrae
Part of bacteria for motility
Flagella
