Week 6: Patient safety Flashcards

1
Q

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

A

Patient safety

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2
Q

Leads to potential or actual adverse events in patients.

A

Unsafe act

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3
Q

If we follow our professional standards, will all patients be safe?

A

not necessarily

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4
Q

Unintended injury related to HC management

A

adverse event

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5
Q

What is the rate of adverse events in Canada?

A

7.5%

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6
Q

AE rate = 7.5%

  • 36.9% of these were ___________
  • 15.9% of AE resulted in _______
A

preventable

death

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7
Q

What are the most common types of AE?

A

Surgical procedures

drug and fluid-related events

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8
Q

How does Ontario compare to Canada for patient safety?

A

Ontario is better than Canada, except in post-op sepsis

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9
Q

Patient safety improvement:

  • Shift in focus to _____ and ____-based care
  • Move to greater attention to _____ _____ rather than ______
A

quality, values

harm reduction, errors

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10
Q

How has the implementation of hospital procedures improved patient safety?

A

Prophylactic treatments for VTE

caring for central lines

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11
Q

What is the biggest challenge to patient safety?

A

Getting away from a culture of blame

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12
Q

CPSI - 6 patient safety goals:
1 - Contribute to _______ of patient safety
2 - Working in _____ for patient safety
3 - _________ effectively for patient safety
4 - _______ safety risk
5 - Optimizing _____ and __________ factors
6 - ______, _______, and _______ adverse events

A
1 - culture
2 - working
3 - communicating
4 - managing
5 - human, environment
6 - recognizing, responding, disclosing
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13
Q

Shared values and beliefs that interact with an organization’s structures and control systems to produce behavioural norms

A

organizational culture

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14
Q

Shared values and beliefs about how we support pt safety

A

patient safety culture

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15
Q

Describe the patient safety culture/barriers and enablers diagram.

A

Patient safety culture – norms and behaviours –> (direct effect) patient safety performance

Patient safety performance has an indirect effect on patient safety culture

Patient safety culture – enabler/barrier –> intervention success (direct)

Intervention success – (direct) –> patient safety performance

Intervention performance - indirect effect - patient safety culture

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16
Q

How does the criminal justice system contribute to a culture of blame?

A

Expects people to be perfect, but we are inexplicably fallible
No harm no foul notion

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17
Q

How can we move away from a culture of blame from a criminal law POV?

A

don’t require perfection

convince that choices do matter

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18
Q

How does HR policy suppress just culture?

A

requires perfection

not a safe environment to disclose and report errors

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19
Q

Is a just culture a blame-free culture?

A

No, people are accountable for exercising free will

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20
Q

What does David Marx say about “just culture”?

A

Finding the balance between keeping pts safe, holding people accountable, but creating a culture where people feel they can come forward and admit their mistakes

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21
Q

Admitting you made a mistake to organization, coordinator, higher ups

A

Reporting

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22
Q

reporting =/= _______

A

disclosure

23
Q

Do we report near misses?

A

Yes

24
Q

30% of AEs are due to a lack of _______.

A

communication

25
Q

Describe the work system diagram.

A

Work system –> process –> outcomes

(work system = tech and tools, organization, person, tasks, environment)
outcomes (pt outcomes, employee and organizational outcomes)

26
Q

Purpose of which is to promote open, frank discussion about the quality of care issues without the fear of reprisal.

A

QCIPA (2004)

27
Q

What type if information collected by QCIPA cannot be used in a court of law?

A

Speculations, opinions, thoughts

28
Q

The decision to use QCIPA is determined by whom?

A

Quality of care committee of the Board

29
Q

What were the implications of the old QCIPA?

A

Cannot discuss the case outside of review meetings
Cannot share information that is not factual for learning purposes
Limited in what can be shared with patient/family

30
Q

What could be shared with pt/family according to the old QCIPA?

A

only actions that have been implemented (cannot be linked back to case)

31
Q

Anything discussed prior to QCIPA being invoked is ___ _________.

A

not protected

32
Q

What was the purpose of the QCIPA update?

A

Affirm rights of patients to access information about their own healthcare
Clarifying that facts about critical incidents cannot be withheld from affected pts and their families
Requires the Minister of Health and LTC to review QCIPA q5years

33
Q

Act that places obligation on HC organizations and hospitals to look at quality of care provided to patients.

A

excellent care for all act (2010)

34
Q

How does the excellent care for all act work?

A

Patient/employee satisfaction surveys, annual QI reports and plans, outlines for performance compensation

35
Q

Unintended event that causes serious injury, harm disability or death

A

Critical incidents

36
Q

Who are we obligated to report a critical incident to?

A

Hospital administration
Medical advisory committee or hospital
patient/SDM

37
Q

Chief of staff, come together and review cases and report to hospital admin about care being provided

A

Medical advisory committee

38
Q

Why was Reg. 965 of the public hospitals act updated?

A

To include the requirement for administrators to ensure full and timely disclosure following critical incidents to medical advisory committees, and patient/SDM

39
Q

Letting the patient/family know what went wrong.

A

Disclosure

40
Q

Process by which a harmful patient safety incident is communicated to the patient or SDM.

A

disclosure

41
Q

Disclosure of harm is based on the principles of _______ and ________
________-________

A

autonomy

informed decision-making

42
Q
Canadian disclosure guidelines:
1 - \_\_\_\_\_\_\_-centered HC
2 - Patient \_\_\_\_\_\_\_
3 - Healthcare that is \_\_\_\_\_
4 - \_\_\_\_\_\_\_ support
5 - \_\_\_\_\_ thing to do
6 - \_\_\_\_\_\_\_ and \_\_\_\_\_\_\_
A
patient
autonomy
safe
leadership
right
honesty, transparency
43
Q

Environment where open, honest, transparent communication occurs between providers and patients

A

patient-centered HC

44
Q

making sure leaders in HC environment are visible, champions of disclosure and are part of pt centered HC

A

Leadership support

45
Q

individuals involved at all levels of decision-making

A

doing the right thing

46
Q

pts have the right to know what happened to them if something bad occurred

A

Patient autonomy

47
Q

Event or situation that could have or did result in unnecessary harm to the patient

A

patient safety incident

48
Q

a patient safety incident that result in harm to the patient

A

harmful incident

49
Q

a patient safety incident which reached the patient but no harm occured

A

no harm incident

50
Q

a patient safety incident that did not reach the patient

A

near miss

51
Q

What were the 4 things Linda said patients wanted?

A

1 - know the truth
2 - Acknowledgement/apology
3 - want to know what the org is doing to prevent it from reoccuring
4 - want support - follow-up and resources

52
Q

True or False?

  1. An apology is an apology. Sincerity doesn’t matter
  2. An apology to a patient is an admission of guilt
  3. An apology to a patient is an admission of legal liability
  4. Apologies are consistent with patient-centered care, honestly and transparency
  5. Nurses should apologize because it is the right thing to do
A
False
False
False
True
True
53
Q

When do we have to disclose an event?

A
Harmful incidents (only that you MUST)
No-harm incident (generally report - since monitoring involved)
54
Q

Key points for disclosure:

  • identify the _____
  • meet to plan what and how the disclosure will take place
  • Disclosure should not be done _____
  • always ______ the disclosure in the patient’s record
  • Follow-up
A

team
not
document