SPECIAL - Non-interpretive skills Flashcards
Reactive, retrospective, “policing”; punitive, finger pointing; “who was at fault after a medical error”; old term - QA/QI/QC?
Quality assurance (QA)
Both prospective and retrospective; avoids assigning blame; goal is to create systems that prevent medical errors; continuous process - QA/QI/QC?
Quality improvement (QI)
System for maintaining a pre-determined level of quality; planning, inspection, corrective action if required - QA/QI/QC?
Quality control (QC)
Six improvement aims for the healthcare system
from IOM; safety, timeliness, effectiveness, efficiency, equity, patient-centeredness (“STEEEP”)
Quality care is…
coordinated, compassionate, innovative
Six core competencies of MOC
medical knowledge, interpersonal/communication skills, patient care, professionalism, practice-based learning/improvement, systems-based practice (“MIPPPS”)
Best practices (2)
dashboards, benchmarking
Measurement of the quality of an organization’s policies, products, programs, and strategy
benchmarking; helps determine improvements, achieve high performance, and improve performance
Visual display of the most important information needed
dashboard
PDSA (acronym)
Plan-Do-Study-Act
PDSA steps
plan = develop hypothesis, do = test hypothesis, study = analyze data, act = draw conclusions and determine next steps
Developing a hypothesis (P, D, S, or A?)
Plan
Testing the hypothesis (P, D, S, or A?)
Do
Analyze the data (P, D, S, or A?)
Study
Draw actionable conclusions and determine next steps (P, D, S, or A?)
Act
Improvement is most effective when… (PDSA)
multiple PDSA cycles are run in parallel or in rapid succession
Major quality improvement methodologies
PDSA, Lean Process Improvement, and Six Sigma
When and who published “To Err Is Human”?
IOM, 1999; part of Quality of Health Care in America project
Number of deaths attributable to medical error per year
44,000 to 98,000
Percentage of hospitalizations in which adverse events occur
3-4%
Percentage of adverse events leading to death
7-14%
Failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim
medical error; highest risk locations are ER, OR, and ICU
Parent organization of Institute of Medicine
National Academy of Sciences (NAS)
Most medical errors were system errors or individual errors?
system errors
Factors contributing to medical errors (from IOM report) (4)
decentralized nature of healthcare, failure to focus on errors, impediment to identify errors, failure of third-parties to incentivize improving safety
Organization funded by congress in response to IOM report
Agency for Healthcare Research and Quality (AHRQ); created in 2000
Purpose of “Never Events” list
to serve as a basis of a mandatory reporting system
Discipline which examines how systems work in actual practice with real human beings
human factors engineering; attempts to design systems that optimize and minimize risk of error
Standardization of equipment and processes is an axiom of…
human factors engineering
Checklists are an example of ________
standardization
Organizations that consistently minimize adverse events despite carrying out instrinsically complex and hazardous work
high reliability organization (HRO)
Characteristics of a HRO
fixation on failure, avoidance of oversimplification, respect of expertise, dedication to resilience, sensitivity to operations (“FARDS”)
Features of a safety culture
acknowledgement of high risk nature of activities, blame-free environment, encouragement of collaboration, commitment of resources to address safety concerns
Authority gradients encourage or undermine safety culture
undermine
Measurement of Safety Culture
surveys of providers at all levels
Examples of Safety Culture surveys
Patient Safety Culture Survey and Safety Attitudes Questionnaire (both from AHRQ)
Teamwork systems, administrative walk-arounds, and unit-based systems are associated with improvements in….
Safety Culture
Model with focus on addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability
Just Culture model
Three manageable behaviors of the Just Culture model
Human Errors, At-risk Behaviors, Reckless Behaviors
In a Just Culture model, the response to an error is predicated on the severity of the event or the type of behavior associated with the event
type of behavior associated with the adverse event; e.g. refusing to do a timeout even if no patient was harmed would result in punitive action
Response to Human Errors (e.g. slips)
Human Errors are consoled
Response to At-risk Behaviors (e.g. shortcuts)
At-risk Behaviors are coached
Response to Reckless Behaviors (e.g. ignoring required safety steps)
Reckless Behaviors are punished
Human Reliability Curve relates…
Human reliability (y-axis) to factor affecting human performance (x-axis); never reaches 100% reliability
Area under Human Reliability Curve
Successful operation (by the human)
Area above Human Reliability Curve
Human error
Person in an organization who takes ownership of processes and foster creation/maintence of the safety culture
safety coach/champion
Primary focus in a safety-report system
the patient, the system, and the event
Healthcare worker who is traumatized by or unduly punished for an error or adverse patient event
second victim; may exhibit signs similar to PTSD
Two broad categories of radiologist errors + which is more common
perceptual errors and cognitive/interpretive errors
Most radiologist errors are cognitive or perceptual?
perceptual (60-80%)
Poor lesion conspicuity, reader fatigue, rapid pace of interpretation, phone calls, and satisfaction of search are examples of which type of radiologist error?
perceptual errors (missed finding which is present in retrospect)
Error analysis tool used to examine serious adverse events
root cause analysis; identifies underlying problem that increases likelihood of errors; avoids focusing on individal mistakes; goal is to eliminate latent errors
Error occurring at the interface between humans and a complex system (in RCA)
active errors (how event occurred)
Hidden problems in healthcare systems that contribute to adverse events (in RCA)
latent errors (why event occurred)
“Quick fix” in root cause analysis
a quick fix may be implemented early in the RCA process to rapidly reduce the risk of a similar error, even though it may not be the definitive solution to a root cause
Accuracy vs. precision - how variable is a test result in ANY given situation?
precision
Accuracy vs. precision - how variably does the test result reflect the desired diagnosis?
accuracy; (TP + TN) / (TP + FN + FP + TN)
Patient identifiers, patient assessment, informed consent, and medication reconcilation are part of what process?
peri-procedural care
Number of patient identifiers that should be used before a procedure
2 or more; include patient name, MRN, phone number, DOB, photo ID, last 4 SSN
Example of a piece of information that cannot be used as a patient identifier
patient location or room number
Which is not an acceptable source of patient identifiers; the patient, a relative, a guardian, a domestic partner, or a healthcare provider who has previously identified the patient?
all are acceptable sources of patient identifiers
Elements of informed consent (5)
discussion of procedure, benefits, potential risks, reasonable alternatives, risk of refusing procedure
Six rights of medication administration
right patient, right medication, right route, right dose, right time, and right documentation
Pre-procedure verification, procedure site marking, and performing a timeout are components of what?
Universal Protocol
Items which must be agreed on during a timeout
correct patient identity, correct site, procedure to be performed; completion of the timeout must be documented
Maximum sterile barrier technique
for more invasive procedures (e.g. central line); defined by National Quality Measures Clearinghouse; cap, mask, sterile gown, sterile gloves, large sterile sheet, hand hygeine, cutaneous sepsis
Which organizations collaborated on the ‘Practice Parameter for Sedation/Analgesia’?
ACR and SIR (Society of Interventional Radiology)
Levels of sedation are defined by whom?
Joint Commission and American Society of Anesthesiologists (ASA)
Levels of sedation (4)
minimal (anxiolysis), moderate, deep, and general anesthesia
Moderate sedation description
patient retains ability to maintain a patent airway and can be aroused by physical/verbal stimulations
ASA class(es) of patients that qualify for moderation sedation
class I (normal healthy patient), class II (mild systemic disease); classes III and IV may require additional consideration for sedation
Discharge criteria after use of a sedation reversal agent
patient’s level of consciousness and vital signs should return to an acceptable level for at least 2 hours prior to discharge
Who was/is responsible for developing/updating the ACR Guidance Document for Safe MR Practices?
Blue Ribbon Panel on MR Safety (which was established by the ACR)
Publically accessible, unrestricted MR zone
zone 1
MR zone for greeting patients, obtaining histories, and screening patient
zone 2; under supervision of MR personnel
Restricted access MR zone(s)
zones 3 and 4
MR zone with physical restriction from entry (door, lock, etc.)
zone 3
MR zone containing the MR magnet
zone 4
First action in the event of a quench
evacuate the room immediately
First action in the event CPR is required (or other medical emergency)
remove patient to a magnetically safe location
Type of gas that fills MR magnet room in a quench
helium gas (displaces oxygen); same process occurs if a tank bursts or there is a helium leak; oxygen levels in the scanner room must be monitored at all times
When must oxygen levels in the MR scanner room be monitored?
at all times
Potentional MR complication of loops of wire, metallic transdermal patches, and large tattoos
skin burns; first two should be removed prior to entry, ice pack may need to be applied to area of tattoo during scanning
T/F - the majority of contrast reactions are mild and self-limited
true
Overall incidence of contrast reactions with low osmolality media
0.2-0.7% (or <1%)
Three goals for contrast administration
appropriate for patient and indication, minimize likelihood of contrast reaction, and be prepared to treat a reaction
