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)
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
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
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
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
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
7
Q
summarize the types of medical errors
A
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)
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
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
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)
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