Week 10 Flashcards
What is patient safety
The reduction and mitigation of unsafe acts within the healthcare system as well as through the use of best practices shown to lead to optimal patient outcomes
What is an incident
Events, processes, practices or outcomes that are noteworthy by virtue of the hazards they create or the harms they cause to patients
What is harm
The product of unsafe acts of safety events
What are the four types of incidents
Harmful incident
Near miss
No-Harm incident
Critical incident
What is the Swiss cheese model
Event passes through several layers to reach the patient. Have to find holes in each layer it passed through, and find ways to prevent them. Prevention at even one layer would stop the event
What is the Domino Model
Event passes through multiple layers (dominos), but as it passes through it creates more momentum (more falling dominos). Have to find ways to stop the momentum. Only have to stop the domino at one layer from falling to stop the event
What is the iceberg model
The incident is only the tip of the iceberg that we can see. Have to look at the submerged (invisible) aspects that led to the event. Correction/prevention often occurs at the invisible level
What is the contributing factor
The reasons, situations, factors, or latent conditions that played a role in the genesis of an adverse event
What is a system failure
Faulty organizational process, operation, or structure that places the patient and/or HCP in danger of harm
Organization safety is shaped by what two forces
The organizational framework and the behaviours demonstrated by the employees of the organization
What are the characteristics of a culture of safety
Reporting culture
Informed culture
Flexible culture
Learning culture
what is risk management
Minimizing the occurrence of untoward events by planning for their occurrence and placing safeguards to offset the danger.
Often takes the form of policies, procedures and processes.
What is quality improvement
Includes activities to enhance the patients (and/or staff’s) experience outcomes and safety
