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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.
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The start time of an invasive procedure is marked by the completion of the procedure.
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A Near Miss is an event that reached the patient and resulted in harm.
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Never Events are patient safety incidents that can be completely controlled with existing practices.
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Harm includes only temporary injuries and does not encompass psychological damage.
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A Never Event can only be categorized if serious harm or death has occurred as a result of a specific incident.
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Non Safety Events include incidents like medication expiration and equipment breakages.
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Patient Safety Culture is defined by the presence of psychological barriers among healthcare workers.
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Psychological Safety refers to the belief that a team is safe for interpersonal risk taking.
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The Safety event management system software is known as The Patient Safety Company or TPSC.
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Serious Reportable Events require no further response beyond an initial classification.
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Systems analysis focuses primarily on blaming individuals for errors in Patient Safety Events.
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Match the following terms with their definitions:
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Match the following components of Patient Safety Culture with their descriptions:
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Match the following events with their categories:
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Match the following terms with their related systems:
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Match the concepts related to safety in healthcare settings:
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Match the following healthcare terminologies with their focus areas:
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Match the following methodologies to their use cases:
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Match the following invasive procedure definitions:
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Match the following safety event terms:
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Match the following definitions with their terms:
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Match the following descriptions with the respective terms:
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Match the following terms with their implications:
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Match the following terms related to patient safety with their definitions:
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Match the following patient safety incidents with their characteristics:
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Match the following methodologies in continuous improvement to their descriptions:
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Match the following terms with their implications in patient care:
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Match the following types of events with their definitions:
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Match the following terms with their descriptions in healthcare:
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Match the following concepts in patient safety management:
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Match the following definitions with their corresponding terms:
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Match the following types of events with their characteristics:
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Match the following components of Patient Safety Culture with their descriptions:
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Match the following types of analyses with their focus:
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Match the following concepts related to patient harm with their explanations:
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Match the following definitions of safety events with their categories:
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Match the following types of healthcare incidents with their features:
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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.