Quality & Patient Safety - Adverse Events And CPSI

Question 1

What are adverse events?

Answer 1

An event or circumstance that could have resulted, or did result, in unnecessary harm to a patient

Question 2

3 types of adverse events

Answer 2

1. Harmful incident - results in harm
2. Near miss - no harm resulted
3. No harm incident - incident reached patient but no harm

Question 3

What are the 4 categories of harmful events?

Answer 3

1. Health care and medications (ex: pressure ulcers, wrong meds)
2. Infections (ex: post procedure/post operative)
3. Procedure related (ex: bleeding post surgery)
4. Patient accidents (ex: falls)

Question 4

Impacts of adverse events? Direct and indirect?

Answer 4

Direct - approx 5 day increase in hospital stay (if someone is harmed they need to stay longer
Indirect - less productivity, increase wages, disability
Health care workers - shame, guilt, absence
Costs - to health care system &/or client

Question 5

Examples of adverse effects

Answer 5

Delayed or missed diagnosis, patient falls, procedural errors, sexual or physical assault, lost or failures to follow up reports, med errors, equipment failure, etc

Question 6

What is CPSI?

Answer 6

Canadian Patient Safety Institute. Organization dedicated to improving patient safety and quality of healthcare in Canada

Question 7

6 core domains?

Answer 7

Fundamental areas important for ensuring patient safety and improving quality of health care

Question 8

1. Patient safety culture

Answer 8

Organizational culture that prioritizes patient safety. All workers feel empowered to report safety risks without fear of reprisal

Question 9

2. Teamwork

Answer 9

Promote effective collaboration & communication among health care team to enhance patient safety

Question 10

3. Communication

Answer 10

Ensuring clear, and effective communication among health care workers, patients, and families to prevent errors

Question 11

4. Safety, risk, and quality improvement

Answer 11

Identifying and mitigating safety risks through quality improvement processes, such as root cause, analysis, and implementing evidence based practices

Question 12

5. Optimize human and system factors

Answer 12

Considering human factors (workload, fatigue) and system factors (technology) to design safer health care

Question 13

6. Recognize, respond to, and disclose patient safety incidents

Answer 13

We must report and tell patients when we’ve made a mistake