Quality Improvement in Healthcare (I) Patient Safety - IHI Modules (PS 101 - 105) Flashcards
What proportion of patients experience some sort of iatrogenic adverse event while hospitalized?
(Examples include: infection, pressure ulcer(s), fall, adverse drug event, etc.)
1 in 10
What percent of adults reported having experienced at least one medical, medication, or lab error/delay between 2014 and 2016?
~20%
(www.healthsystemtracker.org)
Are incompetent or reckless providers the cause of most iatrogenic patient morbidity and mortality?
No (To Err Is Human);
most events are the result of poor communication and result at the hands of even the most competent of providers
In what year did patient safety really take the spotlight as the IoM released ‘To Err Is Human’?
1999
The framework of patient safety revolves around organizational culture and learning systems.
What do these terms mean?
OC - individual and group values, attitudes, competencies, and behaviors;
LS - measures of performance and assistance towards team improvements
What does it meant that patient safety is a ‘dynamic non-event?’
It takes considerable effort and thought to ensure that nothing goes wrong (and we pay much less attention to the non-events)
True/False.
If I make some error resulting in patient death or suffering, I am an incompetent physician.
False.
Nearly all iatrogenic patient increased morbidity and mortality comes as a result of systems failure and can happen to the most skilled physicians
How can we promote a culture of safety in patient care?
Discuss errors openly;
don’t just punish care providers out of principle
What should physician accountability entail?
Holding individuals responsible for acting in a safe and respectful manner WHEN they are given the training and support to do so
How can we as physicians (often the ‘top dogs’ in an environment) promote a culture of psychological safety and openness for our teams so that our patients receive coordinated, safe care?
Make yourself approachable.
Seek to engage all team members.
Encourage feedback.
Respond to suggestions.
Respect and value every team member and his or her input.
True/False.
A just culture should recognize that competent professionals make mistakes; however, it should have zero tolerance for reckless behavior.
True.
True/False.
Many medical errors are system errors more than individual errors.
True.
The following is an example of what type of error?
I notice that I am driving 80 mph in a 65 mph speed zone. It was not my intention, and I reduce my speed.
Human error
The following is an example of what type of error?
I drive 80 mph in 65 mph speed zones as a matter of habit. I am in control and feel comfortable at this speed.
At-risk behavior
The following is an example of what type of error?
I drive 45 mph in 25 mph speed school zones as a matter of habit. I understand this increases the risks to myself, other drivers, and pedestrians, but I choose to stay at this speed.
Reckless behavior
Which of the following should be treated by disciplinary action in the medical field, human error, at-risk behavior, reckless behavior?
Reckless behavior
Patients with highly participatory and engaged families were ___% as likely to experience an adverse event during their hospital stay as those without.
50
A conscious and deliberate (but not malicious) decision to ignore some policy or standard of care is what type of unsafe act?
A violation
A non-deliberate deviation from some normal policy or standard of care conscious is what type of unsafe act?
An error
What are the three main types of unsafe act that result from a medical mistake?
Describe each.
Lapse (forgetting; sin of ommission);
slip (observable action; sin of commission);
mistake (decision-making error; either knowledge- or rule-based)
True/False.
*Medical harm must involve active physical harm leading to further required care.
*Under the IHI Global Trigger Tool
This stringent view of medical harm leaves out what other types?
True.
Psychological harm;
physical harm resulting from errors of ommission;
financial harm
Here is a list of error-reducing principles.
Try to name as many as you can before looking over the list.
In reducing medical error, the term simplification refers to the reduction of:
In reducing medical error, the term standardization refers to the reduction of:
Complexity;
variation
What is a great tool by which errors due to memory can be avoided?
Checklists
