Week 21 Flashcards
what are some motivations of the patient safety and quality movement?
Prominent individual and institutional cases (patel); failures in self-regulation require action by whistle-blowers; Large studies of adverse events/medical error; Variation across systems and institutions in implementation & outcomes; Increased litigation rates and awards; Consumer issues
what are the key moments in the Patient Safety and Quality movement?
Harvard studies & others (1980s); Quality in Australian Health-Care study (mid 1990s); To Err is Human (2000); Australian Council for Safety and Quality in Health Care (2000 - 2006); Australian Commission on Safety and Quality in Healthcare (2006 -); National Open Disclosure Standard (2003);
an Error is defined as?
a planned sequence of activities fails to achieve intended outcome; not attributable to chance
a Mistake is defined as? What two types are there?
An incorrect plan/intention; Rule-based (Application of incorrect rule); Knowledge-based mistake (incomplete or incorrect knowledge)
a Slip is defined as?
correct assessment/plan/intention; slip in carrying out intention
Patient Harm is defined as?
death; disease; injury and/or disability experienced by a patient
a Clinical incident is defined as?
event or circumstance that has actually or could potentially lead to unintended / unnecessary harm to a patient.
An Adverse Event is defined as?
clinical incident in which a patient is unintentionally harmed.
A Near Miss is defined as?
A clinical incident which could have; but did not; result in harm; either by chance or through timely intervention.
a Sentinel Event is defined as?
unexpected occurrence involving death or serious physical or psychological injury; or the risk thereof
the definition of Human Factors Engineering is?
An area of knowledge dealing with the capabilities and limitations of human performance in relation to the design of machines; jobs; and other modifications of the human’s physical environment.
A Root Cause Analysis is defined as?
Systematic process whereby factors that contributed to an incident are identified.
a Systems Failure is defined as?
fault; breakdown or dysfunction within an organisation?s operational methods; processes or infrastructure.
Harm Causes _______ and ought to be _________; Additional Harm should be ___________ and an _____________ made.
Harm causes suffering and ought to be prevented. Harm should be disclosed and apology made
Errors can harm?
Both Doctors and Patients
Relatively few adverse events result from (three things)?
Relatively few adverse events result from negligence; professional misconduct or malicious intent
Making mistakes is necessary for?
Making mistakes necessary for human learning; adapting
May error result from the? List some examples
Many errors result from ?the system?: inadequate training; long hours; ampoules that look the same; lack of check systems etc.
Healthcare has _________ behind other fields in ________ development
Healthcare has lagged behind other fields in safety development
what are the ten steps we can do to increase safety and improve heath care?
- EBM
- Improving communication
- Building safer healthcare systems
- Making individual doctors safer
- Challenging the medical culture
- Supporting informed decision-making
- Disclosing error and apologising
- Working with patients and action groups
- Providing performance data
- Supporting whistle-blowers
what are three things we can do to build a safer healthcare system?
change existing Principles; policies and procedures; Monitor; count and analyse data; Systems improvements (checklists; safer working hours; ect.)
Match the items in the following numerical and alphabetical lists; eg 1a; 2b etc.:
- Medical Error (a) correct assessment/plan/intention; slip in carrying out intention
- Patient Harm (b) clinical incident in which a patient is unintentionally harmed
- Adverse Event (c) clinical incident which could have; but did not; result in harm; either by chance or through timely intervention
- Mistake (d) planned sequence of activities fails to achieve intended outcome; not attributable to chance
- Sentinel Event (e) incorrect plan/intention
- Near Miss (f) event or circumstance that has actually or could potentially lead to unintended unnecessary harm to a patient.
- Slip (g) unexpected occurrence involving death or serious physical or psychological injury; or the risk thereof
- Clinical Incident (h) death; disease; injury and/or disability experienced by a patient.
Match the items in the following numerical and alphabetical lists; eg 1a; 2b etc.:
- Medical Error (d) planned sequence of activities fails to achieve intended outcome; not attributable to chance
- Patient Harm (h) death; disease; injury and/or disability experienced by a patient.
- Adverse Event (b) clinical incident in which a patient is unintentionally harmed
- Mistake (e) incorrect plan/intention
- Sentinel Event (g) unexpected occurrence involving death or serious physical or psychological injury; or the risk thereof
- Near Miss (c) clinical incident which could have; but did not; result in harm; either by chance or through timely intervention
- Slip (a) correct assessment/plan/intention; slip in carrying out intention
- Clinical Incident (f) event or circumstance that has actually or could potentially lead to unintended unnecessary harm to a patient.
Which one of the following is most clearly a method of improving the safety of healthcare systems?
(a) revalidation of doctors at re-registration
(b) mandatory reporting of poorly performing doctors
(c) feedback to clinicians of individual performance data
(d) the use of checklists; eg in prescribing and surgery
(e) clinician improvement services; eg Queensland Health?s CLiPPS
(d) the use of checklists; eg in prescribing and surgery
