Quality and Safety in the Canadian Health Care System

Question 1

Define safety

Answer 1

• freedom from accidental injury

Question 2

Adverse event

Answer 2

• an unintended injury or complication that results in disability at the time of discharge, death or prolonged hospital stay caused by health care management rather than underlying disease process

Question 3

Near miss

Answer 3

An act of commission or omission that could have harmed a patient but did not as a result of chance, prevention or mitigation

Question 4

Define patient safety

Answer 4

“The pursuit of the reduction and mitigation of unsafe acts within the healthcare system, as well as the use of best practices shown to lead to optimal patient outcomes”

• Canadian Patient Safety Institute, 2008; 2009

Question 5

Two common harms concerning patients

Answer 5

1. Mistakes with medication

2. Preventable infections

Question 6

Recommendations on preventing errors

Answer 6

a. periodic re-licensing
b. reporting of events
c. safety as an aim

Question 7

Organizations that set safety standard and evaluate institutions

Answer 7

Canadian Council on Health Services Accreditation (CCHSA)

Safer Healthcare Now (patient safety campaign)

Question 8

Canadian Adverse Events Study (2004)

Answer 8

7.5% severely harmed by health care

37% of avoidable events that negatively affect patient are preventable

Question 9

Apology Act (2009)

Answer 9

Apology means an expression of sympathy or regret…whether or not the words or actions admit fault or liability or imply an admission of fault or liability in connection with the matter to which the words or actions relate”

Question 10

Excellent Care for All Act (ECFAA) 2010

Answer 10

• quality committee that reports to the hospital board of directors on quality-related issues
• annual quality improvement plans
• executive compensation required to achieve improvements
• patient relations process
• surveys to assess satisfaction
• develop declaration of values

Question 11

Incident reports inform quality improvement plans by

Answer 11

identifying where and how management should direct their resources and effort for quality improvement

Question 12

Never Events for Hospital Care in Canada (2015)

Answer 12

Never events: are patient safety incidents that result in serious patient harm or death and are preventable using organization checks and balances
- identify these events, a call-to-action to prevent their occurrence

• never events meet these criteria: serious, recurring, identifiable, avoidable

Question 13

Serious (never event)

Answer 13

high risk event that could result in permanent harm or death

Question 14

Recurring (never event)

Answer 14

event is likely to happen to another patient if not addressed

Question 15

Identifiable (never event)

Answer 15

event that is easily recognized, clearly defined and not attributable to other possible causes

Question 16

Avoidable (never event)

Answer 16

appropriate organizational barriers will prevent the event from occuring

Question 17

The Case of Investing in Patient Safety in Canada (2017)

Answer 17

one in 18 patients in Canadian Hospitals experience preventable harm

Question 18

Error Types

Answer 18

a. Slip - attentional failures
b. Lapse - memory failures
c. Mistake - rule-based mistakes, knowledge-based mistakes

d. Violation (intended actions)

Question 19

Why do we commit errors?

Answer 19

• limited memory
• affected by fatigue and distraction
• required to multi-tasks
• required to perform high-risk activities
• dealing with complex patients, equipment and processes

Question 20

Five levels of care

Answer 20

1. Optimal care and adherence to standards
2. Compliance with standards (ordinary care with imperfections)
3. Unreliable care/poor quality
   (patient escapes harm)
4. Poor care with probable minor harm but overall benefits
5. Care when harm undermines any benefits obtained

Question 21

Three contrasting approaches to safety

Answer 21

a. ultra adaptive (embracing risk)
- taking risks is the essence of the profession (very unsafe)

b. high reliability (managing risk)
- risk is not sought out but is inherent in the profession

c. ultra safe (avoiding risk)
- risk is excluded as far as possible

*different types of care fall on different approaches

Question 22

RNAO Patient Safety Position Statement

Answer 22

• patient safety is a priority in public accountability
• nurses protect and enhance health of clients
• nurses create environments that support patient safety
• patient safety not merely a mandate
• patient safety is a moral and ethical imperative in caring for others

Question 23

5 Safety Strategies

Answer 23

1. Safety as best practice
2. Improving healthcare processes and systems
3. Risk Control
4. Improve capacity for monitoring, adaptation and response
5. Mitigation

Question 24

5 Principles of High Reliability Organization

Answer 24

1. Preoccupation with failure (address failures immediately)
2. Reluctance to simplify (complex problems get complex solutions)
3. Sensitivity to operations (every voice matters)
4. Commitment to resilience (recovery is swift)
5. Deference to expertise (experts are trusted)

Question 25

Define: Quality

Answer 25

The degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge