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
reporting =/= _______
disclosure
Do we report near misses?
Yes
30% of AEs are due to a lack of _______.
communication
Describe the work system diagram.
Work system –> process –> outcomes
(work system = tech and tools, organization, person, tasks, environment)
outcomes (pt outcomes, employee and organizational outcomes)
Purpose of which is to promote open, frank discussion about the quality of care issues without the fear of reprisal.
QCIPA (2004)
What type if information collected by QCIPA cannot be used in a court of law?
Speculations, opinions, thoughts
The decision to use QCIPA is determined by whom?
Quality of care committee of the Board
What were the implications of the old QCIPA?
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
What could be shared with pt/family according to the old QCIPA?
only actions that have been implemented (cannot be linked back to case)
Anything discussed prior to QCIPA being invoked is ___ _________.
not protected
What was the purpose of the QCIPA update?
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
Act that places obligation on HC organizations and hospitals to look at quality of care provided to patients.
excellent care for all act (2010)
How does the excellent care for all act work?
Patient/employee satisfaction surveys, annual QI reports and plans, outlines for performance compensation
Unintended event that causes serious injury, harm disability or death
Critical incidents
Who are we obligated to report a critical incident to?
Hospital administration
Medical advisory committee or hospital
patient/SDM
Chief of staff, come together and review cases and report to hospital admin about care being provided
Medical advisory committee
Why was Reg. 965 of the public hospitals act updated?
To include the requirement for administrators to ensure full and timely disclosure following critical incidents to medical advisory committees, and patient/SDM
Letting the patient/family know what went wrong.
Disclosure
Process by which a harmful patient safety incident is communicated to the patient or SDM.
disclosure
Disclosure of harm is based on the principles of _______ and ________
________-________
autonomy
informed decision-making
Canadian disclosure guidelines: 1 - \_\_\_\_\_\_\_-centered HC 2 - Patient \_\_\_\_\_\_\_ 3 - Healthcare that is \_\_\_\_\_ 4 - \_\_\_\_\_\_\_ support 5 - \_\_\_\_\_ thing to do 6 - \_\_\_\_\_\_\_ and \_\_\_\_\_\_\_
patient autonomy safe leadership right honesty, transparency
Environment where open, honest, transparent communication occurs between providers and patients
patient-centered HC
making sure leaders in HC environment are visible, champions of disclosure and are part of pt centered HC
Leadership support
individuals involved at all levels of decision-making
doing the right thing
pts have the right to know what happened to them if something bad occurred
Patient autonomy
Event or situation that could have or did result in unnecessary harm to the patient
patient safety incident
a patient safety incident that result in harm to the patient
harmful incident
a patient safety incident which reached the patient but no harm occured
no harm incident
a patient safety incident that did not reach the patient
near miss
What were the 4 things Linda said patients wanted?
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
True or False?
- An apology is an apology. Sincerity doesn’t matter
- An apology to a patient is an admission of guilt
- An apology to a patient is an admission of legal liability
- Apologies are consistent with patient-centered care, honestly and transparency
- Nurses should apologize because it is the right thing to do
False False False True True
When do we have to disclose an event?
Harmful incidents (only that you MUST) No-harm incident (generally report - since monitoring involved)
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
team
not
document
