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hospital medicine > Patient safety and Risk Management > Flashcards

Patient safety and Risk Management Flashcards

1
Q

IN 1999, the institute of medicine define patient safety as…. which is often a result of….

A

freedom from accidental injury, which is often a result of error

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2
Q

what is classified as near misses or adverse medical events

A
  • unplanned events that arise from medical care
  • can be due to human or system based error
  • near miss = event that did not cause harm but had the potential to do so
  • Adverse event = injury d/t medical care
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3
Q

what percent of hospitalized patients experience an adverse even d/t medical care during their hospitalization?

A

5-25%

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4
Q

what specific types of medical errors are common in hospitalized patients

A
  • error in the admin of tx
  • failure to order/FU on indicated diagnostics
  • avoidable delays in care and tx
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5
Q

Despite insanely high hospital acquired infections, what is the hand-hygiene rates at most acute care facilities

A

30-70%

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6
Q

what groups of patients are at particularly high risk of medical errors when hospitalized?

A
  • elderly
  • pediatric
  • patients undergoing neuro, thoracic or vascular surgeries
  • patients admitted urgently rather than electively (expecially ICU)
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7
Q

what are the 2 main factors involved in the nature of error in healthcare

A
  • human based error
  • system based errors
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8
Q

What are “human factors”

A
  • environmental, work conditions, organizational, and individual characteristics that influence work performance
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9
Q

what are the categories used to define human performance

A
  • skills
  • rule based actions
  • performance that rely on problem solving
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10
Q

system designs that depend on perfect () are destined to fail at a very HIGH rate

A

perfect human performance!

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11
Q

what are the typical human limitations

A
  • human memory (7+/- 2 elements for short term memery)
  • the need to “cut corners” when rushed
  • stress (causes tunnel vision and filtering)
  • fatigue (impacts short term and long term mem)
  • multitasking, interuptions, environmental ect.
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12
Q

the impact of fatigue is similar to having a …..

A

blood alcohol level of .1%

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13
Q

repeatedly cutting corners or creating “work arounds” can result in a narrow () especially when rushed. This is called ()

A

narrow safety margin

this repetitive act is called the “normalization of deviance”

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14
Q

just look at it

A

mkayyy

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15
Q

what is a system

A

A defined set of interdependent processes designed to accomplish a common aim

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16
Q

what are latent conditions (or latent factors)

A

characteristics of a system that can allow (or even facilitate) individuals to perform unsafe acts

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17
Q

What is the MCC of nosocomial blood stream infections

A

indwelling vascular catheters

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18
Q

Central line associated blood stream infections are associated w a prolonged hospital stay up to (how long) costs about (how much) per episode and continue to have a attributable mortality rate of (what %)

A

3 weeks
50,000$
14-40%

19
Q

what is the MCC of Cental line associated blood strteam infectins? (casues more than 2/3 of infections!)

A

staph!!

both epi and aureus

20
Q

what are potential complications of Cental line associated blood strteam infections?

A

im not learning this but youre welcome to

21
Q

what are some preventative measures for Cental line associated blood strteam infections?

  • use () site instead of () or ()
  • use () technique
  • use () for cutaneous antisepsis peior to placement
  • change peripheral short term caths every () -() hrs
  • clean hubs w () prior to use
  • () catheters that are no longer required
A
  • use subclavian site instead of IJ or femoral
  • use aseptic technique
  • 2% chlorhexidine for cutaneous antisepsis peior to placement
  • change peripheral short term caths every 72-96 hrs
  • clean hubs w 70% ethanol prior to use
  • promptly remove catheters that are no longer required
22
Q

Up to (what %) of elderly pts develope pressure ulcers within the 1st week of hospitalization

A

15%

23
Q

mortality rate can be as high as (what %) for elder persons w pressure ulcer w/i a year of discharge

A

60%

24
Q

What are the main causes/risk factors for pressure ulcers

A
  • friction forces (heels rubbing on sheets)
  • bedbound pts
  • older patients (thinner skin)
  • moisture (facilitates skin breakdown)
25
Q

what are the 5 basic components to comprehensive pressure ulcer prevention

A
  1. risk assessment
  2. skin care
  3. mechanical loading
  4. support surfaces
  5. nutritional support
26
Q

The (name) scale is the most widely used pressure ulcer risk tool in the US. it ranges from 6 (high risk) to 23 (low risk). a score of (what score) is the cut off for onset of pressure ulcer risk

A

“braden scale for predicting pressure sores”

18 is the cutoff

27
Q

when should you perform the braden scale risk score

A
  • on admission
  • at discharge
  • whenever the pts clinical condition changes
28
Q

() should be correlated w risk assessment for pressure ulcers with great attention paid to (what 4 areas)

A

skin assessment

greater trochanter
heels
sacrum
coccyx

60% of all ulcers appear in these locations

29
Q

what skin care routines can help prevent pressure ulcers

A
  1. inspect regularly for erythema, pain, warmth and induration
  2. assess all pressure points and areas that contact medical devices
  3. protect skin from excessive moisture w barrier paste or other products
30
Q

how do you decrease mechanical load to prevent pressure ulcers

A
  • turn/reposition pt Q 2 hrs
  • patients who are critically ill = Q hourly
  • stable patients on specialty beds = Q4 hrs
31
Q

What are support surfaces that can be used in the prevention of pressure ulcers

A

idk heres the slide

32
Q

What is the MC type of adverse event in acute care hospitals

A

falls

33
Q

how odten do falls in the hospital result in an injury

A

nearly 1/3 of the time

34
Q

how many falls are thought to be preventable

A

1/3

so 1/3 preventable and 1/3 ends in injury. got it.

35
Q

pts over (age) are more likely to incur injury because of a fall

A

85

falls are higher among people >65 too

36
Q

where do most falls occur in the hospital

A

pt rooms/bathrooms during transfers between bed/chair while using the toilet/shower

37
Q

I refuse

A

me too

38
Q

Recent hospitalization for medical illnesses accounts for (what %) of all VTE diagnoses

A

25%!!

39
Q

we know this but ima leave it here for review

A
40
Q

what score can be a helpful tool when determining who gets VTE prophylaxis

A

pauda prediction score

41
Q

what is the prophylactic treatment for VTE

A
  • LMWH 40mg SC (CrCl<30 then do 30mg)
  • UFH 5000 units Q8-12hrs
42
Q

what are the risks of prophylactic therapy in VTE

A
  • bleeding (duh)
  • Heparin Induced Thrombocytopenia (HIT)
43
Q

When is HIT more common?

A
  • in surgical patients
  • More common w UFH than LMWh

hospital medicine (6 decks)

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