Podcast
Questions and Answers
An adverse event is an incident that results in unintended harm to the patient from the underlying disease.
An adverse event is an incident that results in unintended harm to the patient from the underlying disease.
False
Clinical risk measures the likelihood of an adverse incident causing injury to a patient.
Clinical risk measures the likelihood of an adverse incident causing injury to a patient.
True
Continuous improvement refers to sudden and drastic changes in the quality of care.
Continuous improvement refers to sudden and drastic changes in the quality of care.
False
A near miss is an event that reached the patient and resulted in harm.
A near miss is an event that reached the patient and resulted in harm.
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Never events are incidents that are largely preventable through established guidelines and safety recommendations.
Never events are incidents that are largely preventable through established guidelines and safety recommendations.
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Invasive procedures include any surgical intervention performed in a surgical environment only.
Invasive procedures include any surgical intervention performed in a surgical environment only.
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Harm includes only permanent injuries to a patient's health.
Harm includes only permanent injuries to a patient's health.
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The start of an invasive procedure is defined as when the first incision is made.
The start of an invasive procedure is defined as when the first incision is made.
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Never Events can only be categorized if serious harm has occurred.
Never Events can only be categorized if serious harm has occurred.
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Patient Safety is the prevention and mitigation of harm caused by errors in healthcare.
Patient Safety is the prevention and mitigation of harm caused by errors in healthcare.
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Psychological Safety is about ensuring a team feels unsafe to take risks openly.
Psychological Safety is about ensuring a team feels unsafe to take risks openly.
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Serious Reportable Events include events that have no consequences for patients or staff.
Serious Reportable Events include events that have no consequences for patients or staff.
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Safety events are unanticipated occurrences that can pose danger in healthcare settings.
Safety events are unanticipated occurrences that can pose danger in healthcare settings.
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Systems analysis aims to blame individuals for errors in patient safety.
Systems analysis aims to blame individuals for errors in patient safety.
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A Patient Safety Culture promotes teamwork and fosters respect among clinicians.
A Patient Safety Culture promotes teamwork and fosters respect among clinicians.
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Non Safety Events directly impact a patient’s health and well-being.
Non Safety Events directly impact a patient’s health and well-being.
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The Safety event management system is referred to as The Patient Safety Company or TPSC.
The Safety event management system is referred to as The Patient Safety Company or TPSC.
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Psychological Safety refers to the ability to give feedback and ask for help without fear.
Psychological Safety refers to the ability to give feedback and ask for help without fear.
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Study Notes
Adverse Event
- An adverse event is an unintended harm to a patient caused by an act of commission or omission, rather than their condition.
Clinical Risk
- Clinical risk is the probability of an adverse incident causing harm to a patient.
Continuous Improvement
- Continuous improvement is a systematic method for consistently improving the quality of healthcare.
- It uses methodologies like PDSA (Plan, Do, Study, Act) cycle, DMAIC (Define, Measure, Analyse, Improve, Control), and A3 problem solving to address workplace issues.
Harm
- Any physical or psychological injury or damage to a person's health, temporary or permanent, is considered harm.
Hazard
- A hazard is anything with the potential to cause harm to patients or healthcare personnel, including damage to health or a threat to their safety.
Invasive Procedure
- An invasive procedure is a surgical intervention, even if performed outside a surgical environment, that permanently alters a patient's anatomy.
- Examples include biopsies, interventional radiology procedures, cardiology procedures, drain and line insertions (e.g., PICC/Hickman lines), and tooth extractions.
- The start time of an invasive procedure is when the first incision is made, tissue is punctured, or an instrument is inserted into tissues, cavities, or organs.
Near Miss
- A near miss is an event that could have resulted in harm to a patient but did not, either by luck or early detection.
Never Event
- Never events are serious, preventable incidents that have the potential to cause serious harm or death to patients.
- They occur in various healthcare settings and are categorized into surgical/invasive procedures, medication, mental health, and general events.
- They are classified as Serious Reportable Events and warrant a comprehensive response to ensure appropriate action and learning take place.
- Each Never Event type has evidence of past occurrence and a risk of recurrence.
Non-Safety Events
- These events occur without directly impacting a patient but may indicate other concerns, such as occupational risks or hazards.
- Examples include equipment breakages, medication breakages/expiration, financial statement errors, and infrastructure damage.
Patient Safety
- Patient safety aims to prevent and reduce harm caused by healthcare errors through systems and processes that minimize the likelihood of errors and maximize the chances of intercepting them when they occur.
Patient Safety Culture
- A patient safety culture fosters a collaborative environment where:
- Clinicians treat each other with respect.
- Leaders promote teamwork and psychological safety.
- Teams learn from errors and near misses.
- Caregivers are aware of human performance limitations in complex systems (stress recognition).
- There's a visible process of learning and continuous improvement through debriefings.
Psychological Safety
- Psychological safety is a team environment where members feel secure to take interpersonal risks.
- This includes giving candid feedback, admitting mistakes, asking for help, and learning from each other.
Safety Event
- A safety event is an unanticipated, undesirable, or potentially dangerous occurrence in a healthcare organization.
Safety Event Management System
- The Patient Safety Company (TPSC) is a central reporting system for capturing near misses and safety events for review, risk rating, and continuous improvement monitoring.
Serious Reportable Events
- These events have serious harm or death consequences for patients, families, staff, or the organization.
- They require a comprehensive response and additional resources to ensure appropriate action and learning take place.
Systems Analysis
- Systems analysis examines the factors contributing to a patient safety event.
- It shifts the focus from blaming individuals to analyzing systems to identify design flaws and proactively prevent accidents through system analysis and design.
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Description
This quiz covers important concepts related to clinical risk and patient safety, including adverse events, hazards, and continuous improvement methodologies. Test your knowledge on how these aspects play a role in healthcare quality and patient care. Enhance your understanding of the potential risks associated with invasive procedures and patient harm.
