Patient safety and Risk Management Flashcards
IN 1999, the institute of medicine define patient safety as…. which is often a result of….
freedom from accidental injury, which is often a result of error
what is classified as near misses or adverse medical events
- 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
what percent of hospitalized patients experience an adverse even d/t medical care during their hospitalization?
5-25%
what specific types of medical errors are common in hospitalized patients
- error in the admin of tx
- failure to order/FU on indicated diagnostics
- avoidable delays in care and tx
Despite insanely high hospital acquired infections, what is the hand-hygiene rates at most acute care facilities
30-70%
what groups of patients are at particularly high risk of medical errors when hospitalized?
- elderly
- pediatric
- patients undergoing neuro, thoracic or vascular surgeries
- patients admitted urgently rather than electively (expecially ICU)
what are the 2 main factors involved in the nature of error in healthcare
- human based error
- system based errors
What are “human factors”
- environmental, work conditions, organizational, and individual characteristics that influence work performance
what are the categories used to define human performance
- skills
- rule based actions
- performance that rely on problem solving
system designs that depend on perfect () are destined to fail at a very HIGH rate
perfect human performance!
what are the typical human limitations
- 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.
the impact of fatigue is similar to having a …..
blood alcohol level of .1%
repeatedly cutting corners or creating “work arounds” can result in a narrow () especially when rushed. This is called ()
narrow safety margin
this repetitive act is called the “normalization of deviance”
just look at it
mkayyy
what is a system
A defined set of interdependent processes designed to accomplish a common aim
what are latent conditions (or latent factors)
characteristics of a system that can allow (or even facilitate) individuals to perform unsafe acts
What is the MCC of nosocomial blood stream infections
indwelling vascular catheters
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 %)
3 weeks
50,000$
14-40%
what is the MCC of Cental line associated blood strteam infectins? (casues more than 2/3 of infections!)
staph!!
both epi and aureus
what are potential complications of Cental line associated blood strteam infections?
im not learning this but youre welcome to
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
- 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
Up to (what %) of elderly pts develope pressure ulcers within the 1st week of hospitalization
15%
mortality rate can be as high as (what %) for elder persons w pressure ulcer w/i a year of discharge
60%
What are the main causes/risk factors for pressure ulcers
- friction forces (heels rubbing on sheets)
- bedbound pts
- older patients (thinner skin)
- moisture (facilitates skin breakdown)
what are the 5 basic components to comprehensive pressure ulcer prevention
- risk assessment
- skin care
- mechanical loading
- support surfaces
- nutritional support
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
“braden scale for predicting pressure sores”
18 is the cutoff
when should you perform the braden scale risk score
- on admission
- at discharge
- whenever the pts clinical condition changes
() should be correlated w risk assessment for pressure ulcers with great attention paid to (what 4 areas)
skin assessment
greater trochanter
heels
sacrum
coccyx
60% of all ulcers appear in these locations
what skin care routines can help prevent pressure ulcers
- inspect regularly for erythema, pain, warmth and induration
- assess all pressure points and areas that contact medical devices
- protect skin from excessive moisture w barrier paste or other products
how do you decrease mechanical load to prevent pressure ulcers
- turn/reposition pt Q 2 hrs
- patients who are critically ill = Q hourly
- stable patients on specialty beds = Q4 hrs
What are support surfaces that can be used in the prevention of pressure ulcers
idk heres the slide
What is the MC type of adverse event in acute care hospitals
falls
how odten do falls in the hospital result in an injury
nearly 1/3 of the time
how many falls are thought to be preventable
1/3
so 1/3 preventable and 1/3 ends in injury. got it.
pts over (age) are more likely to incur injury because of a fall
85
falls are higher among people >65 too
where do most falls occur in the hospital
pt rooms/bathrooms during transfers between bed/chair while using the toilet/shower
I refuse
me too
Recent hospitalization for medical illnesses accounts for (what %) of all VTE diagnoses
25%!!
we know this but ima leave it here for review
what score can be a helpful tool when determining who gets VTE prophylaxis
pauda prediction score
what is the prophylactic treatment for VTE
- LMWH 40mg SC (CrCl<30 then do 30mg)
- UFH 5000 units Q8-12hrs
what are the risks of prophylactic therapy in VTE
- bleeding (duh)
- Heparin Induced Thrombocytopenia (HIT)
When is HIT more common?
- in surgical patients
- More common w UFH than LMWh
