Patient Safety And Quality In Healthcare

Question 1

What is patient safety?

Answer 1

The freedom from accidental injury due to medical care or error.
The prevention of healthcare errors, elimination of injurys caused by healthcare errors.

Question 2

What percentage of patients experience harm in ambulatory settings?

Answer 2

40%

Question 3

What percentage of harm during ambulatory care can be prevented?

Answer 3

80%

Question 4

Explain Murphys Law

Answer 4

Nothing is as easy as it looks, everything takes longer than you expect.
If anything can go wrong it will go wrong. At the worst possible moment.

Question 5

Who said “First, do no harm!”?

Answer 5

Hippocrates

Question 6

Explain what did Florence Nightingale do?

Answer 6

Found out about poor hygiene and infections among soldiers.
Collected data on causes of mortality
Polar area diagram
Hand washing
Ventilation
Reduced death from 42% to 2%
Earliest evidence of “preventable harm in healthcare) [1854]

Question 7

Explain what did Ernest Codman do?

Answer 7

1910
Founder of evidence based medicine

Question 8

Explain what did Avedis Donabedian do?

Answer 8

1966
Evaluating the quality of medical care: structure, process and outcome.
Not bad people but bad systems.

Question 9

Which book shed light on the grave consequences of medical errors and led to substancial increase of awareness?

Answer 9

To err is human (1999)

Question 10

Name the 4 strategies for improvement mentioned in the book To err is human:

Answer 10

1. Create leadership, research and protocols.
2. Raise performance standards.
3. Nationwide reporting systems.
4. Safety systems in healthcare.

Question 11

Who developed the Swiss cheese model and what was its main objetive?

Answer 11

James Reason
To understanding accidents and improving safety, adverse events occur when several faults occur in several layers.

Question 12

Mention 5 root causes of sentinel events:

Answer 12

1.Comunication
2. Orientation
3. Patient assessment
4. Staffing levels
5. Availability of information

Question 13

Steps to minimize a medical error:

Answer 13

Education
Rules
Reminders
Simplifications
Automatization
Forcing function

Question 14

What is a forcing function?

Answer 14

A design feature that prevents errors by making incorrect actions impossible to perform.
Ex; Medication dispensing systems.

Question 15

What is a constrain?

Answer 15

A system limitation that restricts actions to promote safety. Leads you towards the correct action.
Ex; controlled door access.