Healthcare Quality and Safety Overview
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Questions and Answers

An Adverse Event can occur due to an act of commission or omission.

True

Clinical risk refers to the low likelihood of an Adverse Incident causing harm to the patient.

False

Continuous Improvement consists solely of major overhauls in processes.

False

A hazard is defined as any source of potential damage or harm to patients or healthcare personnel.

<p>True</p> Signup and view all the answers

The start time of an invasive procedure is marked by the completion of the procedure.

<p>False</p> Signup and view all the answers

A Near Miss is an event that reached the patient and resulted in harm.

<p>False</p> Signup and view all the answers

Never Events are patient safety incidents that can be completely controlled with existing practices.

<p>True</p> Signup and view all the answers

Harm includes only temporary injuries and does not encompass psychological damage.

<p>False</p> Signup and view all the answers

A Never Event can only be categorized if serious harm or death has occurred as a result of a specific incident.

<p>False</p> Signup and view all the answers

Non Safety Events include incidents like medication expiration and equipment breakages.

<p>True</p> Signup and view all the answers

Patient Safety Culture is defined by the presence of psychological barriers among healthcare workers.

<p>False</p> Signup and view all the answers

Psychological Safety refers to the belief that a team is safe for interpersonal risk taking.

<p>True</p> Signup and view all the answers

The Safety event management system software is known as The Patient Safety Company or TPSC.

<p>True</p> Signup and view all the answers

Serious Reportable Events require no further response beyond an initial classification.

<p>False</p> Signup and view all the answers

Systems analysis focuses primarily on blaming individuals for errors in Patient Safety Events.

<p>False</p> Signup and view all the answers

Match the following terms with their definitions:

<p>Never Events = Serious incidents that have occurred in the past, preventing recurrence Non Safety Events = Events that occur without a direct impact on a patient Safety Event = Unanticipated, undesirable, or potentially dangerous occurrence Patient Safety = Prevention and mitigation of harm caused by errors in healthcare</p> Signup and view all the answers

Match the following components of Patient Safety Culture with their descriptions:

<p>Psychological Safety = Belief that the team is safe for interpersonal risk taking Effective Teamwork = Collaboration and respect among skilled clinicians Learning from Errors = Process of improving through debriefings and near misses Stress Recognition = Awareness of limitations in human performance</p> Signup and view all the answers

Match the following events with their categories:

<p>Equipment breakages = Non Safety Events Medication errors = Patient Safety Events Surgical mistakes = Never Events Financial statement errors = Non Safety Events</p> Signup and view all the answers

Match the following terms with their related systems:

<p>The Patient Safety Company = Safety event management system software Systems Analysis = Understanding factors contributing to Patient Safety Events Serious Reportable Events = Require comprehensive response and resource allocation Psychological Safety = Creating an environment for candid feedback</p> Signup and view all the answers

Match the following definitions with the correct terms:

<p>Serious Reportable Events = Events with serious harm or death consequences Never Events = Incidents that can be completely controlled Patient Safety Culture = Collaborative environment promoting safety Safety Event = Potentially dangerous occurrence within healthcare</p> Signup and view all the answers

Match the concepts related to safety in healthcare settings:

<p>Patient Safety Culture = Collaborative and respectful environment Safety Event Management = Central reporting system for events and near misses Systems analysis = Proactive investigation to prevent future errors Psychological Safety = Encouraging offenders to admit mistakes</p> Signup and view all the answers

Match the following healthcare terminologies with their focus areas:

<p>Patient Safety = Mitigation of harm from healthcare errors Never Events = Prevention of serious incidents in care Serious Reportable Events = Focus on significant patient consequences Non Safety Events = Incidents affecting services but not directly patients</p> Signup and view all the answers

Match the following terms with their definitions:

<p>Adverse Event = An event that results in unintended harm to the patient by an act of commission or omission. Clinical Risks = The likelihood that an Adverse Incident will cause injury or harm to the patient. Harm = Any physical or psychological injury or damage to the health of a person. Hazard = Any source of potential damage, harm, or adverse health effects on patients.</p> Signup and view all the answers

Match the following terms with their descriptions:

<p>Continuous Improvement = The ongoing improvement of products, services, or processes. Invasive Procedure = Interventions that are surgical but may be done outside a surgical environment. Never Events = Patient safety incidents that are largely preventable with known guidelines. Near Miss = An event which did not reach the patient, either through luck or early detection.</p> Signup and view all the answers

Match the following methodologies to their use cases:

<p>PDSA = Plan, Do, Study, Act cycle for problem solving. DMAIC = Define, Measure, Analyse, Improve, Control to enhance quality. A3 Problem Solving = A systematic approach to structured problem-solving. Continuous Improvement = A variety of methodologies used for workplace problem-solving.</p> Signup and view all the answers

Match the following invasive procedure definitions:

<p>Invasive Procedure start time = When the patient's anatomy begins to be permanently altered. Teeth extractions = Considered an invasive procedure within a dental context. Cardiology procedure = An example of an intervention that falls under invasive procedures. Biopsy = A process that involves the removal of tissue for examination.</p> Signup and view all the answers

Match the following safety event terms:

<p>Never Events = Serious Reportable Events that can cause serious patient harm. Harm = Includes both temporary and permanent injuries to health. Clinical Risks = Assessing the potential for harm from adverse incidents. Near Miss = An incident that nearly caused harm but did not reach the patient.</p> Signup and view all the answers

Match the following definitions with their terms:

<p>Hazard = A source of potential damage to patients or healthcare personnel. Clinical Risks = The probability of injury or harm caused by an incident. Harm = Any negative impact to health, psychological or physical. Adverse Event = Incidents resulting from commission or omission actions.</p> Signup and view all the answers

Match the following descriptions with the respective terms:

<p>Invasive Procedure = Includes surgical interventions outside a surgical environment. Continuous Improvement = A systematic approach to enhancing care quality. Adverse Event = Results in unintended harm by acts related to patient care. Never Events = Preventable incidents with strong systemic protective barriers.</p> Signup and view all the answers

Match the following terms with their implications:

<p>Never Events = Patient safety incidents that typically result in serious harm. Near Miss = An event that was averted and did not impact the patient. Harm = Refers to both physical injuries and psychological damage. Clinical Risks = Indicates the risk assessment associated with adverse incidents.</p> Signup and view all the answers

Match the following terms related to patient safety with their definitions:

<p>Adverse Event = An event that results in unintended harm to the patient. Clinical Risks = Likelihood of an adverse incident causing harm. Hazard = Source of potential damage or harm to health personnel. Harm = Physical or psychological injury to a person.</p> Signup and view all the answers

Match the following patient safety incidents with their characteristics:

<p>Near Miss = Event that did not reach the patient. Never Events = Preventable incidents causing serious harm. Invasive Procedure = Surgical interventions conducted outside typical environments. Adverse Incident = Event causing injury or harm to a patient.</p> Signup and view all the answers

Match the following methodologies in continuous improvement to their descriptions:

<p>PDSA = Plan, Do, Study, Act cycle. DMAIC = Define, Measure, Analyze, Improve, Control. A3 = Structured problem-solving methodology. Continuous Improvement = Ongoing enhancement of processes.</p> Signup and view all the answers

Match the following terms with their implications in patient care:

<p>Invasive Procedure start time = When a patient’s anatomy begins to be altered. Never Events = Incidents that have systemic protective barriers. Clinical Risks = The possibility of adverse incidents. Harm = Involves both temporary and permanent injuries.</p> Signup and view all the answers

Match the following types of events with their definitions:

<p>Adverse Event = Unintended harm caused by care provision. Clinical Risk = Likelihood of causing patient injury. Hazard = Potential source of harm. Near Miss = Event caught before it reached the patient.</p> Signup and view all the answers

Match the following terms with their descriptions in healthcare:

<p>Continuous Improvement = Incremental and breakthrough enhancements. Hazard = Potential threats to safety. Never Events = Incidents that should never occur. Invasive Procedure = Involves surgery or similar interventions.</p> Signup and view all the answers

Match the following concepts in patient safety management:

<p>Never Events = Serious reportable events mostly preventable. Adverse Incident = Can cause harm or injury. Clinical Risks = Assessment of potential injury likelihood. Harm = Includes psychological impact.</p> Signup and view all the answers

Match the following definitions with their corresponding terms:

<p>Harm = Physical or psychological injury. Adverse Event = Unintended patient harm. Invasive Procedure = Surgical-like interventions. Near Miss = Event that fortunately did not reach the patient.</p> Signup and view all the answers

Match the following types of events with their characteristics:

<p>Never Events = Serious incidents that are preventable and result in harm Non Safety Events = Incidents without direct patient impact Serious Reportable Events = Events with serious harm or death consequences Safety Events = Unanticipated, undesirable occurrences in healthcare</p> Signup and view all the answers

Match the following components of Patient Safety Culture with their descriptions:

<p>Collaboration = Teams learn from errors and near misses Leadership = Drivers of effective teamwork Respect = Skilled clinicians treating each other with honor Debriefings = Visible processes for learning and improvement</p> Signup and view all the answers

Match the following types of analyses with their focus:

<p>Systems analysis = Understanding interactions within a system Risk assessment = Evaluating potential hazards Incident reporting = Capturing safety-related near misses Root cause analysis = Identifying the underlying causes of events</p> Signup and view all the answers

Match the following terms with their definitions:

<p>Psychological Safety = A belief that the team is safe for interpersonal risk taking Patient Safety = Prevention of harm caused by healthcare errors Safety Event Management = System for reporting and reviewing safety incidents Serious Harm = Severe consequences affecting patients or staff</p> Signup and view all the answers

Match the following concepts related to patient harm with their explanations:

<p>Error of omission = Failure to provide necessary care Error of commission = Providing incorrect treatment Harm = Adverse effects resulting from healthcare actions Near Miss = Incidents that could have caused harm but did not</p> Signup and view all the answers

Match the following definitions of safety events with their categories:

<p>Adverse Event = Harm resulting from healthcare management Medication Error = Mistakes in prescribing, dispensing, or administering drugs Surgical Error = Mistakes made during surgical procedures Equipment Failure = Faults in medical devices used in care</p> Signup and view all the answers

Match the following types of healthcare incidents with their features:

<p>Equipment Breakages = Non Safety Event affecting operational efficiency Medication Expiration = Non Safety Event signaling potential risk Infrastructural Hazards = Non Safety Event impacting patient care indirectly Financial Statement Error = Non Safety Event indicating financial mismanagement</p> Signup and view all the answers

Study Notes

Adverse Events

  • An event that results in unintended harm to the patient.
  • Caused by an act of commission or omission rather than the underlying disease or condition of the patient.

Clinical Risks

  • The likelihood that an Adverse Incident will cause injury or harm to the patient.

Continuous Improvement

  • Ongoing improvement of products, services or processes.
  • A systematic, sustainable approach to enhancing the quality of care and outcomes for patients.
  • Methodologies to solve problems in the workplace include:
    • PDSA (Plan, Do, Study, Act) cycle
    • DMAIC (Define, Measure, Analyse, Improve, Control)
    • A3 problem solving

Harm

  • Any physical or psychological injury or damage to the health of a person, including both temporary and permanent injury.

Hazard

  • Any source of potential damage, harm, adverse health effects on patients or healthcare personnel or any threat to their safety.

Invasive Procedure

  • Interventions that are surgical but may be done outside a surgical environment.
    • Blocks for pain relief
    • Biopsy
    • Interventional radiology procedure
    • Cardiology procedure
    • Drain insertion and line insertion (e.g. peripherally inserted central catheter (PICC)/ Hickman lines)
    • Teeth extractions

Invasive Procedure Start Time

  • The start of an invasive procedure is when a patient’s anatomy begins to be permanently altered.
    • This is when the first incision is made that will scar the patient and take time to heal and recover from.

Near Miss

  • Event which DID NOT reach the patient, either through luck or early detection.

Never Events

  • Part of the Serious Reportable Events category.
  • Patient safety incidents that are largely preventable through the implementation of known and available guidelines or safety recommendations.
  • Have the potential to cause serious patient harm or death.
  • Can occur in various settings within healthcare and are grouped into:
    • Surgical/invasive procedure
    • Medication
    • Mental Health
    • General

Non Safety Events

  • Events that occur without a direct impact on a patient.
  • May point to other concerns such as occupational risks or hazards.
    • Equipment breakages
    • Medication breakages/expiration
    • Financial statement errors
    • Infrastructure damage or hazards

Patient Safety

  • The prevention and mitigation of harm caused by errors of omission or commission associated with healthcare.
  • Involves the establishment of systems and processes that minimise the likelihood of errors and maximise the likelihood of intercepting them when they occur.

Patient Safety Culture

  • A collaborative environment in which skilled clinicians treat each other with respect.
  • Leaders drive effective teamwork and promote psychological safety.
  • Teams learn from errors and near misses.
  • Caregivers are aware of the inherent limitations of human performance in complex systems (stress recognition).
  • There is a visible process of learning and driving improvement through debriefings.

Psychological Safety

  • A shared belief held by members of a team that the team is safe for interpersonal risk taking.
  • Giving candid feedback, openly admitting mistakes, being willing to ask for help and learning from each other.

Safety Event

  • An unanticipated, undesirable, or potentially dangerous occurrence in a healthcare organisation.

Safety Event Management system

  • The Safety event management system software is called The Patient Safety Company or TPSC.
  • It is a central reporting system in which safety-related near misses and events are captured for review, risk rating and future continuous improvement monitoring.

Serious Reportable Events

  • Events that have serious harm or death consequences to patients and families, staff or the organisation.
  • Warrant a comprehensive response and the use of additional resources to ensure appropriate action and learning take place.
  • Include never events.

Systems analysis

  • Looks at the many factors that contributed to a Patient Safety Event.
  • A shift from blaming individuals for errors to analysing systems to uncover design flaws.
  • Moving from addressing problems reactively to proactively preventing accidents through system analysis and design.

Adverse Events

  • Unintended harm to a patient due to a healthcare provider’s action or inaction.
  • Examples of adverse events include medication errors, surgical complications, and falls.

Clinical Risks

  • The likelihood of an adverse incident causing injury or harm to a patient.
  • Assessing clinical risks helps healthcare providers to anticipate and mitigate potential harm.

Continuous Improvement

  • Ongoing enhancement of products, services, or processes.
  • It’s a systematic approach to raising the quality of care and patient outcomes.
  • Methods used in Continuous Improvement include PDSA, DMAIC, and A3 problem solving.

Harm

  • Physical or psychological injury to a person’s health, including temporary and permanent damage.

Hazard

  • Any source of potential harm or adverse health effects on patients or healthcare personnel.

Invasive Procedures

  • Interventions that permanently alter a patient’s anatomy.
  • Examples include surgical procedures, biopsies, interventional radiology procedures, and drain insertion.

Invasive Procedure Start Time

  • Marked by the initial incision, puncture, or insertion of an instrument into tissues, organs, or cavities.

Near Miss

  • An event that did not reach the patient, either through luck or early detection.
  • Near misses are valuable learning opportunities for improving patient safety.

Never Events

  • Serious, largely preventable patient safety incidents.
  • They have the potential to cause serious harm or death, even if no harm occurs.
  • Examples include wrong-site surgery, retained foreign objects, and administration of incompatible blood.

Non Safety Events

  • Occur without a direct impact on a patient, often related to operational concerns or hazards.
  • Examples include equipment breakages, medication expiration, and infrastructure damage.

Patient Safety

  • Involves preventing and mitigating harm caused by healthcare errors.
  • Focuses on establishing systems and processes to minimize errors and maximize their detection.

Patient Safety Culture

  • A collaborative workplace environment with respect, effective teamwork, psychological safety, learning from errors, and a culture of improvement.

Psychological Safety

  • A team environment where members feel safe to take interpersonal risks.
  • It enables open communication, honest feedback, and learning from mistakes.

Safety Event

  • Unanticipated, undesirable, or potentially dangerous occurrence in a healthcare organization.

Safety Event Management System

  • A central reporting system for safety-related near misses and events, called The Patient Safety Company (TPSC).
  • Used for review, risk rating, and continuous improvement monitoring.

Serious Reportable Events

  • Events with serious harm or death consequences to patients, staff, or the organization.
  • Warrant a comprehensive response and additional resources to ensure appropriate action and learning.

Systems Analysis

  • Examination of multiple contributing factors to a patient safety event.
  • Shifts the focus from blaming individuals to analyzing systems to uncover design flaws and proactively prevent harm.

Adverse Events

  • Defined as an unintended harm to a patient caused by healthcare actions (commission) or inactions (omission).
  • Distinct from harm caused by the patient's underlying condition.

Clinical Risks

  • Represent the likelihood of an Adverse Incident causing harm to a patient.

Continuous Improvement

  • A systematic and ongoing process to enhance the quality of healthcare.
  • Involves methodologies like PDSA cycle, DMAIC, and A3 problem solving.

Harm

  • Any physical or psychological injury to a patient, including both temporary and permanent effects.

Hazard

  • A potential source of harm to patients or healthcare personnel, including threats to their safety.

Invasive Procedure

  • Surgical interventions performed inside or outside a surgical environment.
  • Examples include biopsies, interventional radiology procedures, and line insertions.
  • Start time is marked when patient's anatomy is permanently altered (e.g., first incision).

Near Miss

  • An event that could have caused harm but didn't due to luck or early detection.

Never Events

  • Serious and largely preventable patient safety incidents.
  • Occur across various healthcare settings (surgical, medication, mental health, general).
  • Require comprehensive response and learning to prevent recurrence.

Non-Safety Events

  • Events with no direct patient impact but may indicate other concerns like equipment breakages, medication issues, or financial errors.

Patient Safety

  • The prevention and mitigation of harm caused by healthcare errors.
  • Involves creating systems and processes to minimize errors and maximize their interception.

Patient Safety Culture

  • A work environment that prioritizes teamwork, respect, and psychological safety.
  • Encourages open feedback, learning from errors, and continuous improvement.

Psychological Safety

  • A shared belief within a team that it's safe to take risks.
  • Fosters open communication, mistake admissions, and learning.

Safety Event

  • An unexpected and potentially dangerous occurrence in a healthcare organization.

Safety Event Management System

  • TPSC (The Patient Safety Company) is a central reporting system for safety events and near misses.
  • It facilitates review, risk rating, and continuous improvement monitoring.

Serious Reportable Events

  • Patient safety events with serious harm or death consequences.
  • Require comprehensive response and resource allocation for learning and improvement.

Systems Analysis

  • Examines the various factors contributing to a patient safety event.
  • Shifts focus from individual blame to system design flaws, promoting proactive accident prevention.

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Description

This quiz covers key concepts related to adverse events, clinical risks, and continuous improvement in healthcare. It also explores methodologies for enhancing patient safety and quality of care. Test your understanding of harm, hazards, and invasive procedures in a clinical setting.

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