QA #4 Flashcards by Abigail Colvin

The quality or condition of being safe; freedom from danger, injury, or damage

Safety

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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

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Events, actions, or things that can cause harm.

Hazards

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Preventable adverse events or near misses during the provision of healthcare services.

Medical Errors

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Adverse event involving death or serious physical or psychological injury

Sentinel Event

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“all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome

Errors

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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

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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

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Improper selection of an objective or a plan of action

Judgment errors

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Proper plan carried out improperly

Execution Error

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Required tasks not done

Errors of omission

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Tasks not required to be done that are done

Errors of Commission

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Committed by frontline workers usually immediately seen

Active Errors

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Results of failure from the control of upper levels of the organization

Latent Errors

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What are some factors against safety in healthcare?

Blaming
Reliance on perfect human performance
Poor working conditions (faulty system design)

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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

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T/F Safety programs provide an environment in which hazards are eliminated or minimized for employees, staff, patients, and visitors.

True

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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

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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

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What is the ultimate goal for safety?

To lessen the risk of errors

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When a process, procedure, or service does not perform as intended, it is considered ___________, and this situation threatens patient safety.

Unreliable

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If an error does occur, ________________should prevent the mistake from reaching the patient.

reliable safeguards

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T/F

Patient care processes should be designed so the chances of harmful errors are minimized.

True

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If the error does reach the patient, ________________ should act quickly to reduce the amount of harm to the patient.

response mechanisms

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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)