Week 6 (Class 1) - Patient Safety Flashcards
What is the definition of patient safety (CPSI)?
“Patient safety, defined as the reduction and mitigation of unsafe acts within the healthcare system, and the use of best practices shown to lead to optimal patient outcomes, is a critical aspect of quality healthcare.” (CPSI, 2009)
How often does patient harm happen in hospitals?
1/18 hospital stays (2014-2015)
- This is about 138,000 out of 2.5 million hospital stays
What kind of harmful events happen in the hospital?
1) Health care and medications
2) Infections
3) Procedure related
4) Patient accidents
What is the public knowledge of Canadian Health Care Issues?
3/10 admit they know PT safety well
4/10 say the know a little
2/10 say they have heard about it
5% say they’ve never heard about it
*6/10 know more about hospital wait times
Who are more likely to know about PT safety?
Caregivers and those with chronic illness
What factors can compromise PT safety?
- Failing to check identity of patients
- Medications (i.e. underlying condition or allergies)
- Multiple drugs
- Misuse of technology
- Poor Communication
- Delays in treatment
- Unreliable supply of drugs
- Environment
- Infection control
- Lack of radiation protection
- Medical devices malfunctioning
Categories
- Individual
- System
What is the Swiss Cheese Model of System Failure Reason?
Successive Layers of Defence
- Holes are due to active failures
- Other holes due to latent factors
- Slice is the defensive layer
Overall, problems should be caught
- Catastrophic is when all the holes align = flawed system results in adverse outcome
What is incident analysis terminology?
1) Factors
- Latent errors - organization processes (i.e. environmental, team, individual, task, patient)
- Active factors (i.e. programming a pump wrong)
2) Categories of unsafe events
- Harmful incident - harm to PT
- Near miss - did not reach PT = no harm
- No harm incident
3) Violations
- Routine (i.e. hand hygiene)
- Optimizing
- Necessary
What are factors leading to latent errors?
1) Institutional/regulatory
2) Organizational/Management
3) Work Environment
4) Team Environment
5) Staffing
6) Task-related
7) Patient Characteristics
What are some reasons why errors occurs?
- Human factors
Human Factors
- Limited knowledge
- Poor application of knowledge
- Fatigue
- Sub-optimal teamwork
- Attention distraction
- Inadequate training
- Reliance on memory
- Poor handwriting
What are some reasons why errors occurs?
- Human factors
Human Factors
- Limited knowledge
- Poor application of knowledge
- Fatigue
- Sub-optimal teamwork
- Attention distraction
- Inadequate training
- Reliance on memory
- Poor handwriting
What is the culture of blame?
- Why do we blame?
- We blame because of professional accountability
What is the culture of blame?
- Why do we blame?
VIDEO - Annie
Blame culture = blaming for failure and mistakes; human nature to find answers and assign blame
- Swiss Cheese Model - number of things need to go wrong
We blame because of professional accountability
- Maintain competence
CNA Code of Ethics Professional accountability: Nursing and Patient Safety
- Patient safety needs to mean more than the definition for nurses
“Being under the care of a professional health-care provider who, with the person’s informed consent, assists the patient to achieve an optimal level of health while ensuring that all necessary actions are taken to prevent or minimize harm. Patient safety is fundamental to nursing care and to health care more generally, across all setting merely as and sectors. It is not a mandate; it is a moral and ethical imperative in caring for others.”
How can nurses apply patient safety thinking in all clinical activities?
- Relationships with patients
- Understand multiple factors involved in failures
- Avoid blaming when an error occurs
- Practice evidence-based care
- Maintain continuity of care
- Awareness of the importance of self-care
- Act ethically everyday
Safety Competency Framework includes:
- Teamwork
- PT safety culture
- Recognize, response to, and disclose PT safety incidents
- Optimize human and system factors
- Safety, risk, and quality improvement
- Communication
What to do when an error occurs?
Document and report all events that affect patient safety
harmful incidents, near miss, no harm incidents
Communicate with the patient/family, healthcare team, and management (incident reporting)
WHY report an event that did not cause harm to a patient?
No one will know why or how that event occurred
- No way to prevent in the future that could actually cause harm to PT’s
Why do harmful events occurs?
Not intentionally
- Due to complexity of healthcare systems
Why do harmful events occurs?
Not intentionally
- Due to complexity of healthcare systems
What do we need to identify about ourselves to promote PT safety?
- Knowledge
- Skills
- Behaviours
- Attitudes
What do we need to identify about ourselves to promote PT safety?
- Knowledge
- Skills
- Behaviours
- Attitudes
What is a harmful event?
Unintended outcome of care that may be prevented with practiced
- identified and treated in the same hospital stay
- reflects PT experience
Reporting:
- Serious adverse drug reactions or medical device incident
WHO video in lecture
Changes have required industries, hospitals, and unregulated partied - mandatory to report
- Timelines
- Hospitals = in writing within 30 days
