Patient Safety and Quality Improvement

Question 1

What proportion of patients experience some sort of iatrogenic adverse event while hospitalized?

(Examples include: infection, pressure ulcer(s), fall, adverse drug event, etc.)

Answer 1

1 in 10

Question 2

Are incompetent or reckless providers the cause of most iatrogenic patient morbidity and mortality?

Answer 2

No (To Err Is Human);

most events are the result of poor communication and result at the hands of even the most competent of providers

Question 3

In what year did patient safety really take the spotlight as the IoM released ‘To Err Is Human’?

Answer 3

1999

Question 4

The framework of patient safety revolves around organizational culture and learning systems.

What do these terms mean?

Answer 4

OC - individual and group values, attitudes, competencies, and behaviors;

LS - measures of performance and assistance towards team improvements

Question 5

What does it mean that patient safety is a ‘dynamic non-event’?

Answer 5

It takes considerable effort and thought to ensure that nothing goes wrong (and we pay much less attention to the non-events)

Question 6

True/False.

If I make some error resulting in patient death or suffering, I am an incompetent physician.

Answer 6

False.

Nearly all iatrogenic patient increased morbidity and mortality comes as a result of systems failure and can happen to the most skilled physicians

Question 7

How can we promote a culture of safety in patient care?

Answer 7

Discuss errors openly;

don’t just punish care providers out of principle

Question 8

What should physician accountability entail?

Answer 8

Holding individuals responsible for acting in a safe and respectful manner WHEN they are given the training and support to do so

Question 9

How can we as physicians (often the ‘top dogs’ in an environment) promote a culture of psychological safety and openness for our teams so that our patients receive coordinated, safe care?

Answer 9

Make yourself approachable.

Seek to engage all team members.

Encourage feedback.

Respond to suggestions.

Respect and value every team member and his or her input.

Question 10

True/False.

A just culture should recognize that competent professionals make mistakes; however, it should have zero tolerance for reckless behavior.

Answer 10

True.

Question 11

True/False.

Many medical errors are system errors more than individual errors.

Answer 11

True.

Question 12

The following is an example of what type of error?

I notice that I am driving 80 mph in a 65 mph speed zone. It was not my intention, and I reduce my speed.

Answer 12

Human error

Question 13

The following is an example of what type of error?

I drive 80 mph in 65 mph speed zones as a matter of habit. I am in control and feel comfortable at this speed.

Answer 13

At-risk behavior

Question 14

The following is an example of what type of error?

I drive 45 mph in 25 mph speed school zones as a matter of habit. I understand this increases the risks to myself, other drivers, and pedestrians, but I choose to stay at this speed.

Answer 14

Reckless behavior

Question 15

Which of the following should be treated by disciplinary action in the medical field, human error, at-risk behavior, reckless behavior?

Answer 15

Reckless behavior

Question 16

Patients with highly participatory and engaged families were ___% as likely to experience an adverse event during their hospital stay as those without.

Answer 16

50

Question 17

A conscious and deliberate (but not malicious) decision to ignore some policy or standard of care is what type of unsafe act?

Answer 17

A violation

Question 18

A non-deliberate deviation from some normal policy or standard of care conscious is what type of unsafe act?

Answer 18

An error

Question 19

What are the three main types of unsafe act that result from a medical mistake?

Describe each.

Answer 19

Lapse (forgetting; sin of ommission);

slip (observable action; sin of commission);

mistake (decision-making error; either knowledge- or rule-based)

Question 20

True/False.

*Medical harm must involve active physical harm leading to further required care.

*Under the IHI Global Trigger Tool

This stringent view of medical harm leaves out what other types?

Answer 20

True.

Psychological harm;

physical harm resulting from errors of ommission;

financial harm

Question 21

Here is a list of error-reducing principles.

Try to name as many as you can before looking over the list.

Answer 21

Question 22

In reducing medical error, the term simplification refers to the reduction of:

In reducing medical error, the term standardization refers to the reduction of:

Answer 22

Complexity;

variation

Question 23

What is a great tool by which errors due to memory can be avoided?

Answer 23

Checklists

Question 24

What is one method by which communication errors can be reduced in healthcare settings?

Answer 24

Repeat everything back

(questions and answers)

(to colleagues and patients)

Question 25

What is a useful phrase for checking what you should be doing or ensuring someone else is doing their work properly?

Answer 25

‘I need some clarity about…’

Question 26

What is the SBAR method of critical information transmission/presentation?

Answer 26

Situation

Background

Assessment

Recommendation(s)

Question 27

What percentage of serious iatrogenic adverse patient events can be linked to transitions between care givers and/or care giving teams?

Answer 27

80%

Question 28

What comes first when you realize you have made a mistake and caused an averse incident to occur?

Answer 28

The patient’s well-being

Question 29

Must every near-miss error (undetected by the patient) be shared with the patient?

Answer 29

No;

this may weaken patient trust

Question 30

What are the four elements of a complete apology?

Answer 30

Acknowledgement;

explanation;

expression of remorse, shame, and/or humility;

reparation (amends)

Question 31

According to a survey in The Lancet, when patients and families pursue lawsuits against their providers, which of the following is one of the things they want most?

a) Publicity
b) Increased public reporting of errors
c) Tougher laws
d) An explanation

Answer 31

d) An explanation

Question 32

Although African-Americans make up only 12% of the U.S., they make up what percentage of new HIV diagnoses?

Answer 32

~50%

Question 33

Name as many of the six points of quality control (mentioned by the IoM Quality Chasm report) as you can, and then briefly review the attached image.

Note: The quality challenge is STEEEP.

Answer 33

Question 34

What are four basic components that should be understood and considered when evaluating quality improvement?

Answer 34

Appreciation of the system components

Variance in results

Theory of knowledge

Human psychology

Question 35

According to the IOM report Unequal Treatment, diversity in the health care workforce is an important part of making care more equitable.

Why?

Answer 35

1. Health professionals from minority groups are more likely to work in service to those groups, improving access to care.
2. Racial, ethnic, and language concordance between provider and patient is associated with greater patient participation in care, higher patient satisfaction, and improved adherence to treatment.