QA #4 Flashcards
The quality or condition of being safe; freedom from danger, injury, or damage
Safety
Actions undertaken by individuals and organizations to protect healthcare recipients from being harmed by the effects of healthcare services; also defined as freedom from accidental or preventable injuries produced by medical care.
Patient Safety
Events, actions, or things that can cause harm.
Hazards
Preventable adverse events or near misses during the provision of healthcare services.
Medical Errors
Adverse event involving death or serious physical or psychological injury
Sentinel Event
“all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome
Errors
an event that results in unintended harm to the patient and is related to the care or services provided the patient, rather than the underlying condition of the patient
Adverse Event
an event or situation that did not produce patient harm because it did not reach the patient, either due to [being] capture[d] before reaching the patient; or if it did reach the patient, [did not cause harm] due to robustness of the patient or to timely intervention
Near Miss
Improper selection of an objective or a plan of action
Judgment errors
Proper plan carried out improperly
Execution Error
Required tasks not done
Errors of omission
Tasks not required to be done that are done
Errors of Commission
Committed by frontline workers usually immediately seen
Active Errors
Results of failure from the control of upper levels of the organization
Latent Errors
What are some factors against safety in healthcare?
- Blaming
- Reliance on perfect human performance
- Poor working conditions (faulty system design)
what are the multiple factors healthcare professionals decisions and actions are influenced by
- organization culture
- personal attitudes and qualifications
- composition of the workgroup [teamwork and respect]
- physical resources available
- design of the work systems and processes
T/F Safety programs provide an environment in which hazards are eliminated or minimized for employees, staff, patients, and visitors.
True
Risk management, emergency preparedness, hazardous materials management, radiation safety, environmental safety and hygiene, security, and preventive maintenance are all activities in which what is promoted
Safety
T/F
To improve patient safety, systems and processes must be examined to see if changes are needed to increase the chance that a patient will be harmed.
False-Increase
What is the ultimate goal for safety?
To lessen the risk of errors
When a process, procedure, or service does not perform as intended, it is considered ___________, and this situation threatens patient safety.
Unreliable
If an error does occur, ________________should prevent the mistake from reaching the patient.
reliable safeguards
T/F
Patient care processes should be designed so the chances of harmful errors are minimized.
True
If the error does reach the patient, ________________ should act quickly to reduce the amount of harm to the patient.
response mechanisms
Just culture and safety have what four tasks surrounding safety
Reporting, Reliability, Learning, and Just
what are Instruments (paper or electronic) used to document occurrences that could have led or did lead to undesirable results.
Incident Reports
Incident reports are completed by who when a patient and/or employee are involved in an event.
An employee
Give some examples of some reportable events
- Patient fall
- Malfunction of a medical device resulting in potential or actual injury
- Diagnostic or testing problem
- Error that occurs during the delivery of patient care
- Development of a condition seemingly unrelated to a patient’s disease
T/F
Measures of patient safety allow organizations to identify unsafe processes and practices that need investigating and improving.
True
What type of safety measure is this?
Notifies leaders/employees after an undesirable event occurs
Reactive
What type of safety measure is this?
Alerts leaders/employees of potential risky conditions or situations, which if not performed to the appropriate standard, could result in an adverse event.
Proactive
T/F All staff within an organization must be comfortable reporting mistakes so everyone can learn from the mistake.
True
What are the essentials for a reporting environment?
- Protect
- Allow
- Separate
- Provide
- Make
Name the reporting environment.
________ people involved against disciplinary proceedings (as far as is practical).
Protect
Name the reporting environment.
________ confidential reporting or deidentify the reporter.
Allow
Name the reporting environment.
___________ the agency or department collecting and analyzing the reports from those that have the authority to institute disciplinary proceedings and impose sanctions.
Separate
Name the reporting environment.
________ rapid, useful, accessible, and intelligible feedback to the reporting community
Provide
Name the reporting environment.
________reporting easy
Make
Systematic assessment of a process to identify the location, cause, and consequences of potential failure for the purpose of eliminating or reducing the chance of failure.
Failure Mode and Effects Analysis (FMEA)
To find hazards and make process changes to reduce (or eliminate) the risk of error.
FMEA’s Goal
A structured process for identifying the underlying factors that caused a (potential or actual) adverse event.
Root Cause Analysis (RCA)
To find system deficiencies that led to the event.
RCA’s Goal
To improve quality, an organization must have what four things?
- Will to improve
- Capacity to translate that will into positive change
- Infrastructure necessary to support improvement
- Environment hospitable to quality
- Involves meeting or exceeding customer expectations
- Is dynamic
- Can be improved
Quality
“the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
Quality
what is considered quality today may not be considered quality tomorrow=
Dynamic
Measurable capability of a process, procedure, or health services to perform its intended function in the required time under commonly occurring conditions.
Reliability
A discipline that applies scientific know-how to a process, procedure, or health service activity so that it will perform its intended function for the required time under commonly occurring conditions.
Reliability Science
The simplest way to measure performance reliability is through ________ & __________
process output or outcomes
T/F
The number of actions that
achieve the intended results (numerator)
are divided by
the total number of actions taken (denominator).
True
The reliability of commercial aviation is better than 99.9999 percent, with an extremely _______ of a complete engine failure leading to loss of aircraft.
Low risk
When improvement actions rely mostly on people’s _________ & ________ to get things done correctly
vigilance and hard work
the best level of reliability that can be achieved is what?
80 to 90 percent
What are the levels of organization culture/
Level 1: Observable culture
Level 2: Shared-values
Level 3: Common assumptions
Which level?
The way things are done in the organization
Level 1: Observable culture
which level?
Realities that members take for granted and share as a result of their joint experiences
Level 3: Common assumptions
which level?
Awareness of organizational values and recognition of their importance
Level 2: Shared-values
T/F
People often work in complex healthcare environments with clearly designed mistake-proofing infrastructures
False-Without
The environmental, organizational and job factors, and individual characteristics which influence behavior at work
Human Factors
Fail 40 to 60 percent of the time in some hospital processes.
- Hand Hygiene
- (Hand-off)Communication
Processes that do not generally lead to patient death or severe injury within hours of a failure (e.g., hand hygiene, administration of low-risk medications).
Noncatastrophic processes
Processes with a high likelihood of patient death or severe injury immediately or within hours of a failure (e.g., identification of correct surgery site, administration of compatible blood for a transfusion).
catastrophic processes
Interventions to improve performance are most successful when they address what three things?
- the individuals doing the work
- the way in which work gets done
- the system(s)
When introducing workflow changes, automation, new roles, and other interventions designed to improve performance
consider the needs of the people involved and how they will be affected
T/F
To ensure people are as effective as possible in their job, cognitive overload must be maximized
False- Minimized
a situation in which the demands of the job exceed the individual’s ability to mentally process all the information encountered regarding a situation
Cognitive overload
When process improvements come undone, the cause often can be traced back to the attitudes or behaviors of the people doing the work—behaviors that should have been modified but were not
Change Behaviors
T/F
Process improvement efforts tend to focus on standardizing and error-proofing work steps and sometimes overlook the human part of the process
True
Understanding what contributes to the attitudes or behaviors is at the heart of knowing how to _______ attitudes and behaviors.
modify
Changes to processes are often implemented without a clear understanding of how the change affects other parts of the system—the people, other processes, and services.
Test redesigned processes
Test process changes, before they are implemented, on a small subset of activities or patients (usually 5 to 10 individuals).
Test redesigned processes
If the changes achieve the __________, they can be applied to all activities or patients
intended goals
T/F
Quantitative and qualitative data should be collected during the pilot phase of a process change.
True
The _______ helps the project team see the impact changes will have on the people doing the work as well as related activities and systems
data
The data can convince others of the __________the changes organization-wide.
value of adopting
- It is important to keep improvement plans tracked and (the organization’s) leaders informed of outstanding and completed actions items.
- Always report any barriers (issues) or concerns prohibiting the fulfillment of an improvement plan or ongoing improvement action
Monitor Performance
- Project goals guide decisions about what needs to be changed in the process and how best to accomplish the changes
- Useful and accurate performance information is needed to judge the success of action plans
Measure Effectiveness
Create standardization through specific processes and staff education and ________.
vigilance
Standardization improves what?
Patient safety
Achieving 80 to 90 percent reliability can be done in what four ways
- Develop defined protocols
- Require use of common equipment or supplies
- Create checklists (decision aids)
- Develop methods for reducing process variations (eliminate waste) and improve efficiencies (optimal outcomes)
Create standardization through specific processes and staff education and vigilance.= what percent?
80-90%
Use sophisticated failure prevention and basic failure identification and mitigation strategies= what percent?
95%
Achieving 95 percent reliability can be done in what ways
- Build decision aids and reminders into the system
- Set the desired action as the default (based on scientific evidence)
- Specify process risks, and articulate actions for reducing risks
- Take advantage of scheduling
- Use redundant processes
- Measure and provide feedback on compliance with process specification
Some healthcare process should function at 99.5 percent reliability or better because failures within them are likely ________ for patients.
catastrophic
To achieve 99.5 percent performance or greater requires what……
- Identifying failures (document, monitor)
- Determining how often the failures occur (document, monitor)
- Understanding why the failures occur (document, monitor)
- Agree on a measure for assessing reliability (i.e., baseline, goals, success)
