Safety Quiz 1 Flashcards
what is the Joint Comission (TJC)
one of the bigger Hospital accrediting agencies
see if complying with CMS conditions
HFAP and DNV (other hospital accrediting agencies)
what are the 3 standards from the joint commission that we discussed
- culture of safety
- use of systems for blame free reporting of a system or process failure
- uses data and info to guide decisions
what is the HITECH act
hospitals got money to use electronic health records (now get penalized if not using it)
what is POCA
phonetic and orthographic computer analysis
way to check how similar drug names are - aka how possible for mix ups
Poison and prevention packaging act?
Packaging that is significantly difficult for children under 5 years of age to open
for substances include controlled and prescription drugs
drug quality and security act of 2013?
- Registration of compounding facilities
- Introduces “track-and-trace” with identifiers down to the package level
TJC has national pt safety goals
started in 2002:
ex: label medications before a procedure
caution with blood thinnrs
perform med rec
what is NQF
national quality form
they will:
measure culture
approves standards/organization wide awareness
increase public access
they say “health orgs: must systematically identify and mitigate patient safety risks and hazards”
just SO MANY safe practices they come out with
what is a CPOE
computerized prescriber order entry (per NQF - this is required)
what is MDRO
multidrug resistant organism eradication program (NFQ says this is a must)
_____ comes out with the targeted best practices
ISMP!
they also have the do not use - abbreviations list!/and sound a like drug list
USP 800 is about?
hazardous drugs
USP 1066 is about?
physical environment (lighting, distractions, noise) and med safety zones!! (outlining things, layout of materials, ease of access)
ASHP came out with stuff that was like hey, get a med safety leader…
Big qualities:
proactively develop ______
and provide ______
develop error mitigation strategies
provide med safety education to others
3 modes of human factors: \_\_\_\_\_\_ performance \_\_\_\_\_\_ performance & \_\_\_\_\_\_ performance
skill based (auto pilot)
rule based (if then response mode)
knowledge based (figuring it out mode)
skill based performance types of errors:
____ and _____
slip and lapse
fix by stopping and thinking about it
rule based performance types of errors:
3 things?
used the wrong rule, misapplied rule, chose to not follow the rule
Elements of a safe culture?
recruitment/training with safety in mind
open communication about harmful events/impacts
establish “just culture”
organizational commitment to error detection/reporting
common understanding that med use is high risk
what organizations measures culture safety?/what surveys did degnan highlight
AHRQ/agency for healthcare research and quality
SAQ - safety attitudes questionnaire
definition of human factors engineering?
discovers and applies information about human capabilities, limitations, and other characteristics to design better technologies, tools, and systems
pt safety definition
and
med safety definition?
pt: prevention of errors and adverse effects to patients associated with health care
med safety: freedom from accidental injury due to medical care or medical errors
during the medication-use process
Medication error definition?
any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of a healthcare provider, pt, or consumer
Omission or comission
(omiss: lack of action; comiss: did this instead of that)
Near miss definition?
any event that could have had adverse consequences [for the patient] but did not”
aka close call; potential ADE
ADE definition?
drug related injury; results from administration of a drug
example: confusion about how pt should take med
ADR definition?
response to a drug that is noxious and unintended and occurs at doses normally used in [people] for the prophylaxis, diagnosis, or
therapy of disease, or for modification of physiological function.
an ADR is always an ADE!!!
Sentinel Event definition?
unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof — needs immediate investigation and response
training is not appropriate if …
System design not considered first Errors occurring across many people (3+ Already trained and problem persists ‘Stop using in the wrong way’ ‘Be more vigilant’
