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
