PATIENT SAFETY AND QUALITY IMPROVEMENT Flashcards
Wrong plan to achieve a desired aim
Medical error
An error reaches the patient but does not result in harm
Non-intercepted near miss error
Recognized and corrected errors before it reaches the patient
Intercepted near miss error
An unexpected occurrence of death or serious physical or psychological injuries
Sentinel event
A 4-year-old child with leukemia who requires a transfusion receives the wrong type of blood, resulting in a serious transfusion reaction
Sentinel event
When a sentinel event has been identified, an investigation is undertaken immediately to determine the root causes that have led to the event. An action plan is then developed and implemented to monitor the system in order to minimize the risk that such an event will recur in the future
Root cause analysis
A patient who is allergic to penicillin was prescribed amoxicillin and developed a skin rash after drug administration
Preventable medical error
A patient with no history of allergic reaction to penicillin developed a severe allergic reaction to amoxicillin
Non-preventable medical error
Suspected child physical or sexual abuse is an example of
Mandatory reporting
Serious reportable hospital events that should not have occurred, resulting in death or significant disability
Never events
Mistakenly, a surgery was performed on the healthy left knee instead of the right knee with torn ligaments
Surgical never event
Frequent nonclinically relevant alarm alerts result in desensitization to the alarms, and caregiver may miss some signals that should necessitate an intervention
Alarm fatigue (adjust alarm thresholds to reduce nonclinically relevant noises); patients’ variability should be considered
What are some ways to prevent dosing and medication errors?
Avoid trailing zeros such as 20.0mg Use leading zeros such as 0.1mg Avoid abbreviations such as BID Write out unit
What are some ways to prevent medication administration errors?
Syringes are the preferred dosing device, measuring cups and spoons calibrated and marked in milliliters are acceptable alternatives
Child in your clinic received the wrong immunization; what should be done in this situation?
Provide apology to parents The error should be disclosed to the parents in a clear manner, and the steps that need to be taken to prevent further errors should be discussed
