patient safety, QI Flashcards
active error
occur at point of interface between humans and system - e.g. ordering wrong med or overriding alert
latent error
problems with system that contribute to adverse event
writing out numbers
zeroes before decimal, never after
adverse event
injury caused by medical management - harm must be caused
adverse drug event
injury resulting from use of drug; may be due to medication error or unforeseen reason (e.g. unknown drug allergy)
near miss event
medical error places patient at risk for injury without actually resulting in injury
intercepted error
noted before it gets to the patient
non-intercepted error
gets to the patient, may or may not cause injury
sentinel event
unexpected actual/potential death or serious injury as a result of medical care
- all require root cause analysis
never event
serious reportable event that is an error that was identifiable, preventable, and have serious consequences for patient
frequency of adverse events
1% of pediatric hospitalizations
60% preventable
cost of medical errors
37 billion per year
barriers to reporting errors
- fear of blame
- fear of appearing incompetent
- fear of being whistleblower
- fear of litigation
triggering
“smoking gun” technique to identify adverse events
e.g. auditing all charts where drug was used to reverse sedation in order to identify ADE with sedative
disclosing error
- be transparent: why, impact, next steps
- apologize!
- suspend judgment of competence
- provide support through debriefing
