Quality and Safety in the Canadian Health Care System Flashcards
Define safety
- freedom from accidental injury
Adverse event
- 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
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
Define patient safety
“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
Two common harms concerning patients
- Mistakes with medication
2. Preventable infections
Recommendations on preventing errors
a. periodic re-licensing
b. reporting of events
c. safety as an aim
Organizations that set safety standard and evaluate institutions
Canadian Council on Health Services Accreditation (CCHSA)
Safer Healthcare Now (patient safety campaign)
Canadian Adverse Events Study (2004)
7.5% severely harmed by health care
37% of avoidable events that negatively affect patient are preventable
Apology Act (2009)
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”
Excellent Care for All Act (ECFAA) 2010
- 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
Incident reports inform quality improvement plans by
identifying where and how management should direct their resources and effort for quality improvement
Never Events for Hospital Care in Canada (2015)
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
Serious (never event)
high risk event that could result in permanent harm or death
Recurring (never event)
event is likely to happen to another patient if not addressed
Identifiable (never event)
event that is easily recognized, clearly defined and not attributable to other possible causes
