Week 6: Patient safety Flashcards
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
Patient safety
Leads to potential or actual adverse events in patients.
Unsafe act
If we follow our professional standards, will all patients be safe?
not necessarily
Unintended injury related to HC management
adverse event
What is the rate of adverse events in Canada?
7.5%
AE rate = 7.5%
- 36.9% of these were ___________
- 15.9% of AE resulted in _______
preventable
death
What are the most common types of AE?
Surgical procedures
drug and fluid-related events
How does Ontario compare to Canada for patient safety?
Ontario is better than Canada, except in post-op sepsis
Patient safety improvement:
- Shift in focus to _____ and ____-based care
- Move to greater attention to _____ _____ rather than ______
quality, values
harm reduction, errors
How has the implementation of hospital procedures improved patient safety?
Prophylactic treatments for VTE
caring for central lines
What is the biggest challenge to patient safety?
Getting away from a culture of blame
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
1 - culture 2 - working 3 - communicating 4 - managing 5 - human, environment 6 - recognizing, responding, disclosing
Shared values and beliefs that interact with an organization’s structures and control systems to produce behavioural norms
organizational culture
Shared values and beliefs about how we support pt safety
patient safety culture
Describe the patient safety culture/barriers and enablers diagram.
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
How does the criminal justice system contribute to a culture of blame?
Expects people to be perfect, but we are inexplicably fallible
No harm no foul notion
How can we move away from a culture of blame from a criminal law POV?
don’t require perfection
convince that choices do matter
How does HR policy suppress just culture?
requires perfection
not a safe environment to disclose and report errors
Is a just culture a blame-free culture?
No, people are accountable for exercising free will
What does David Marx say about “just culture”?
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
Admitting you made a mistake to organization, coordinator, higher ups
Reporting
