Quality and Safety in Health Care Flashcards
Define safety.
- freedom from accidental injury or preventable injury
- failure of a planned action to be completed as intended
Define adverse event.
an unintended complication that results in disability at the time of discharge, death, or prolonged hospital stay that is caused by health care management rather than by the patient’s underlying disease process
Define near miss.
an act of commission or omission that could have harmed a patient but did not as a result of chance, prevention, or mitigation
What were the major findings in the Canadian Adverse Events Study?
- 7.5% of Canadian patients are severely harmed by health care
- 37% of normally avoidable events that negatively affect the patient’s health or well-being are considering preventable
What does the ECFAA cover?
- quality committees in hospital
- quality improvement plans
- executive compensation for achieving improvements
- patient/family feedback
- staff feedback on satisfaction
- declarations of values
What are ‘never events’?
- patient safety incidents that result in serious harm or death and that are preventable using organizational checks and balances
- serious, reoccurring, identifiable, avoidable
What is a slip?
- unintended action
- attentional failures: intrusion, omission, reversal, disordering, mistiming
What is a lapse?
- unintended action
- memory failures: omitting planned items, place-losing, forgetting intentions
What is a mistake?
- intended action
- rule-based mistakes: misapplication of good rule, application of bad rule
- knowledge-based mistakes: many verbal forms
What is a violation?
- intended action
- routine violation
- exceptional violation
- acts of sabotage
Describe the ‘Swiss cheese’ model in relation to patient safety.
- holes line up and result in patient harm
- procedures, physical barriers, information, decisions –> poor protocols, faulty equipment, missing information, inadequate supervision
What are the five levels of care?
- optimal care and adherence to standards
- compliance with standards; ordinary care with imperfections
- unreliable care/poor quality; the patient escapes harm
- poor care with probable minor harm but overall benefits
- care where harm undermines any benefits obtained
Define ‘quality’ and the associating factors.
- the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge
- factors: effective, timely, efficient, equitable, safe, patient centred
What are the contributing factors to a culture of safety?
Just culture - competent people unwillingly make mistakes, often due to system issues, should receive support, not blame
Reporting culture - encouraging, supporting and rewarding the reporting of patient safety incidents and risks. sharing information from reporting to inform improving
Learning culture - having knowledge of patient safety science and the skills and resources to address safety issues
Improving culture - commitment to analyzing and addressing safety issues and concerns and sharing the lessons throughout the organization including opportunities for improvement
What is the RNAO patient safety position statement?
- patient safety priority
- RNs protect and enhance the health of patients
- nurses create environments that support patient safety
- not merely a mandate, but moral and ethical imperative
