Patient Safety

Question 1

Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization, or that results in death.

Answer 1

harm

Question 2

When an error does not lead to an adverse outcome, it is called…

Answer 2

a “near miss”

Question 3

What are the 3 types of error?

Answer 3

• Skill based (slips and lapses)
• Rule based (mistakes and violations)
• Knowledge based (bias)

Question 4

What is the most frequent cognitive error physicians make?

Answer 4

premature closure - concluding Dx early and failing to be inclusive of other differentials

Question 5

What is Team STEPPS?

Answer 5

Strategies and Tools to Enhance Performance and Patient Safety - emphasizes communication and team work

Question 6

What is the #1 contributor to medical errors?

Answer 6

fatigue

Question 7

What is Human Factors Engineering (HFE)?

Answer 7

To mistake-proof what we do by standardizing (to limit unwanted variability), simplifying processes, and error-proofing processes

Question 8

What are some HFE solutions?

Answer 8

-forcing functions and constraints
-checklists/protocols
-warnings/labels
-rules/policies
-training/education
-exhortation
(from strongest to weakest efficacy)

Question 9

What were some of the reasons behind the success of the Sydney Area case we talked about with optimizing emergency intubation for children to 91% first-pass success?

Answer 9

• standardization
• training and ongoing assessment
• cognitive aids
• monthly review of all cases

Question 10

Cognitive errors are caused by ___________.

Answer 10

natural human bias