Risk Management & Patient Safety Flashcards
In 1999 the Institute of Medicine released what book talking about medical errors
To Err is Human
Most errors are blamed on who?
Not one person, faulty process
What is the AHRQ
Agency for Healthcare Research and Quality
Houses the national guideline clearinghouse
What is ASHRM?
American Society for Healthcare Risk Management?
-early roots in OH
What is HEN and what is its purpose?
Hospital Engagement Network
-shared data and implement improvement strategies
What is IHI
Institute for Healthcare Improvement
- non profit
- voluntary initiatives to improve pt safety
Current goals of ASHRM & HEN programs:
Decrease Inpt errors/ harm by 40%
Decrease readmission by 20%
Most common source of error seen in
Medications
Top 5 Medication ADR requiring hospitalization:
Insulin Anticoagulants Amoxicillin Aspirin Bactrim -40% were unintentional overdoses
Common errors in insulin
improper monitoring
Look alike packages
Abbreviations
Common errors in anticoagulants
Inadequate monitoring
drug drug internxs
Common errors in narcotics
Drug drug internx & sedation
Respiratory depression
multiple formulations
mg vs ml
What drug accounts for 40% of acute liver failure causes
acetaminophen
Major cause of CAUTI
indwelling catheters
A tunneled central line is usually placed
passed under skin, usually chest
What sites should be avoided for central line placement?
Femoral
Most falls are which of the following:
Anticipated
Unanticipated
Accidental
Anticipated 78%
Is bed rest appropriate for a pt on falls cautions?
NO
accelerates bones loss, immobility, etc
Common sites of pressure ulcers:
heels/ankles knees hips spine/tailbone elbows shoulder blades ears/back of head
Surgical infections lead to
more likely admitted to ICU
5x more likely to readmitted
2x mortality rate
What is the mot common preventable cause of hospital death?
venous thromboembolism
What is ABCDE bundle and what is it used to reduce?
Use to reduce ventilator associated pneumonia
Awakening & Breathing trial Coordination
Delirium assessment
Early Progressive Mobility
