Patient Safety Flashcards

1
Q

describe the common causes of unsafe medical care

A
  • medication errors
    • 1.5 million deaths occur each year in the US due to medication error
    • common causes
      • poor handwriting, dosing or route of administration errors, look-like drugs
  • hospital-acquired infxns (HAI)
    • 5-15% of all hospitalized patients get an HAI
    • 40% of all ICU patients get an HAI
    • adverse events and injuries due to medical devices
      • urinary catheter-related infxns (UTI): 40% of all HAI
    • hospital acquired pneumonia
      • 2nd most common nosocomial infxn
    • surgical site infections (SSI)
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2
Q

name the structural factors that contribute to unsafe care

A
  • organizational determinants and latent failures
  • lack of structural accountability
    • use of accreditation and regulations to ensure patient safety
  • non-existant safety culture
  • lack of training, education of human resources
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3
Q

name the human factors that contribute to unsafe care

A
  • communication and teamwork failure
  • errors at times of transitions or handoffs
  • stress and fatigue
  • note: potential for human error amplified by poor working conditions
    • production pressure
    • IM SAFE
      • illness, medication, stress, alcohol, fatigue, eating
  • lack of appropriate knowledge and its transfer
  • devices and procedures with no human factors
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4
Q

name the process factors that contribute to unsafe care

A
  • misdiagnosis
  • poor test follow-up
  • counterfeit and substandard drugs
  • lack of involvement of patients in patient safety
  • no teamwork training
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5
Q

name the 3 main types of medical errors

A
  • slips
    • actions not carried out as intended or planned
    • e.g. injecting a medication intravenously when you meant to give it subcutaneously
  • lapses
    • missed actions and omissions
    • e.g. forgetting to monitor and replace serum potassium in a patient treated with furosemide for acute CHF
  • mistakes
    • a wrong intended action, e.g. a faulty plan or incorrect intention
    • e.g. extubating a patient prematurely based on misapplication of guidelines
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6
Q

describe a violation

A

not a type of medical error

  • violations
    • deliberate actions whereby someone does something and knows it to be against the laws
    • e.g. deliberately failing to follow proper procedures
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7
Q

summarize the types of medical errors

A
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8
Q

describe the different outcomes of errors

A
  • adverse events
    • harm or injury that results directly from the management of a patients disease or condition by health care professionals rather than by the underlying disease or condition itself
  • near-misses
    • errors that occur but do not result in injury or harm to patients because they are caught in time or simply because of luck
  • sentinel event
    • adverse event in which death or serious harm to a patient has occurred: used to refer to events that were not at all expected or acceptable (e.g. an operation on the wrong patient or body part)
  • violation
    • intentional or deliberate deviation from safe operating procedures, standards, or policies (not an error)
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9
Q

describe reporting of sentinel events vs near misses

A
  • sentinel events
    • disclosed to patient and family and reported to hospital
  • near-misses
    • not disclosed to patients or families; however, should be reported to the hospital in order for error to be studied in attempt to learn how to prevent it in the future
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10
Q

name the 3 types of diagnostic errors

A
  • no-fault errors
    • may happen when there are masked or unusual symptoms of a disease, or when a patient has not fully cooperated in care
  • systems-related errors
    • technical failure, equipment problems and organizational flaws
  • cognitive errors
    • diagnoses that are wrong, missed, or unintentionally delayed due to clinician error
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11
Q

name the 3 types of common cognitive errors

A
  • anchoring bias
    • a wrong diagnosis made when clinician holds on to a particular diagnosis and dismisses other signs and symptoms that point to another diagnosis
  • confirmation bias
    • looking for evidence to support a pre-conceived opinion rather than looking for evidence that refutes it or provides greater support to an alternative diagnosis
  • availability bias
    • tendency to assume a diagnosis based on recent patient encounters or memorable cases (i.e. the most cognitively “available” diagnosis)
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12
Q

describe the 2 methods of analysis of medical errors

A
  • root cause analysis
    • retrospective approach applied after failure event to prevent reoccurrence
  • failure mode and effects analysis
    • forward-looking approach applied before process implementation to present failure occurrence
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