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 20.0 mg
Use leading zeros such as 0.1 mg
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
