Healthcare Risk Management

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Questions and Answers

Match the following terms with their definitions:

Adverse Event = An event that results in unintended harm to the patient by an act of commission or omission Harm = Any physical or psychological injury or damage to the health of a person Hazard = Any source of potential damage or adverse health effects on patients or healthcare personnel Near Miss = Event which DID NOT reach the patient, either through luck or early detection

Match the following terms with their descriptions:

Never Events = Patient safety incidents that are largely preventable through known guidelines Invasive Procedure = Interventions that may be surgical but done outside a surgical environment Continuous Improvement = Ongoing enhancement of quality of care and outcomes for patients Clinical Risks = Likelihood that an Adverse Incident will cause injury or harm to the patient

Match the following methodologies with their usage in Continuous Improvement:

PDSA = Plan, Do, Study, Act cycle DMAIC = Define, Measure, Analyse, Improve, Control A3 Problem Solving = Structured problem-solving approach Incremental Improvement = Ongoing improvement through small changes

Match the following terms related to healthcare with their implications:

Harm = Includes both temporary and permanent injury Adverse Event = Results in unintended harm to the patient Invasive Procedure start time = When a patient's anatomy begins to be permanently altered Clinical Risks = Likelihood of injury or harm due to Adverse Incidents Signup and view all the answers

Match the following invasive procedures with their examples:

Biopsy = Involves tissue sampling for analysis Cardiology Procedure = Intervention related to heart conditions Teeth Extractions = Dental surgery to remove teeth Line Insertion = Inserting a catheter into the body Signup and view all the answers

Match the following types of events in healthcare:

Never Events = Serious Reportable Events that are largely preventable Adverse Incidents = Events that may harm a patient Clinical Risks = Identifies potential for patient injury Near Miss = Did not reach the patient due to early detection Signup and view all the answers

Match the terms related to patient safety with their descriptions:

Hazard = Potential threat to safety of patients or staff Continuous Improvement = Systematic approach to enhance quality of care Near Miss = Event that effectively didn’t harm the patient Adverse Event = Injury caused by healthcare actions Signup and view all the answers

Match the following statements with the correct term:

Invasive Procedure start time = When the first incision is made that scars the patient Adverse Event = Unintended harm resulting from an act or omission Clinical Risks = Probabilities affecting patient safety Never Events = Incidents preventable through effective guidelines Signup and view all the answers

Match the following terms with their correct definitions:

Patient Safety = The prevention and mitigation of harm caused by errors in healthcare. Psychological Safety = A shared belief that the team is safe for interpersonal risk taking. Never Events = Serious incidents that can lead to harm or death even without a direct incident. Safety Event = An unanticipated, potentially dangerous occurrence in healthcare. Signup and view all the answers

Match the following categories with their descriptions:

Surgical/invasive procedure = Type of Never Event involving surgical errors. Medication = Never Event related to medical prescription errors. Mental Health = Never Event affecting patient mental health care. General = Broad category of Never Events not specifically defined. Signup and view all the answers

Match the following types of events with their implications:

Non Safety Events = Occur without direct patient impact but indicate concerns. Serious Reportable Events = Events leading to serious consequences warranting comprehensive response. Safety event management system = Central reporting system for near misses and safety-related events. Systems analysis = Focuses on systemic factors contributing to patient safety events. Signup and view all the answers

Match the following components of a Patient Safety Culture:

Respect among clinicians = Encourages effective teamwork. Learning from errors = Involves debriefings and continuous improvement. Leaders promoting teamwork = Drives a culture of safety. Awareness of human limitations = Acknowledges stress recognition in complex systems. Signup and view all the answers

Match the following concepts with their characteristics:

Patient Safety Culture = Collaborative environment for safety. Systems approach to harm reduction = Focus on design flaws rather than individual blame. Safety event = Potentially dangerous occurrence needing management. Serious Reportable Events = Require resources for appropriate action and learning. Signup and view all the answers

Match the following strategies with their goals:

Safety Event Management System = Captures and reviews safety-related incidents. Systems analysis = Creates proactive prevention strategies through analysis. Patient Safety initiatives = Minimize errors and maximize intercepting processes. Psychological Safety promotion = Encourages candid feedback and open communication. Signup and view all the answers

Match the definitions with the correct events:

Equipment breakages = Example of a Non Safety Event. Risk of recurrence = Applicable to types of Never Events. Infrastructure damage = Non Safety Event indicating hazards. Comprehensive response = Necessary after Serious Reportable Events. Signup and view all the answers

Match the following professionals with their roles in Patient Safety:

Clinicians = Treat each other with respect and support teamwork. Leaders = Drive the culture of safety and continuous improvement. Caregivers = Aware of human limitations and stress recognition. Teams = Learn from errors and actively engage in debriefings. Signup and view all the answers

Match the following principles with their applications:

Error omission = Involves failure to act leading to patient harm. Error commission = Involves incorrect actions resulting in harm. Systems perspective = Moves from reactive to proactive harm prevention. Collaborative environment = Encourages a culture centered on safety. Signup and view all the answers

Study Notes

Adverse Events

Unintended harm to a patient caused by an act of commission or omission.
Not caused by the patient's underlying disease or condition.

Clinical Risks

The likelihood of an Adverse Incident causing injury or harm to a patient.

Continuous Improvement

Ongoing improvement of products, services, or processes through incremental and breakthrough improvements.
A systematic and sustainable approach to enhancing the quality of care and patient outcomes.
Methodologies used for structured problem-solving include:
- PDSA (Plan, Do, Study, Act) cycle
- DMAIC (Define, Measure, Analyze, Improve, Control)
- A3 problem solving

Harm

Any physical or psychological injury or damage to a person's health, including 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.
Examples include:
- Blocks for pain relief
- Biopsy
- Interventional radiology procedure
- Cardiology procedure
- Drain insertion
- Line insertion (e.g., 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 for example:
- The first incision that will scar the patient
- Surgical incision
- Tissue puncture
- Insertion of an instrument into tissues, cavities, or organs

Near Miss

An event that did not reach the patient, either through luck or early detection.

Never Events

Patient safety incidents that are largely preventable through known and available guidelines or safety recommendations.
These events have the potential to cause serious patient harm or death.
Serious harm or death does not need to have happened for an incident to be categorized as a Never Event.
Each Never Event type has evidence of occurrence in the past.
They are grouped into:
- Surgical/invasive procedure
- Medication
- Mental Health
- General

Non-Safety Events

Events that occur without a direct impact on a patient.
They may point to other concerns such as occupational risks or hazards.
Examples include:
- Equipment breakages
- Medication breakages/expiration
- Financial statement errors
- Infrastructure damage or hazards

Patient Safety

Prevention and mitigation of harm caused by errors of omission or commission associated with healthcare.
Establishment of systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.

Patient Safety Culture

A collaborative environment where:
- 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.
It's about 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 organization.

Safety Event Management System

The software used to manage safety events is called The Patient Safety Company (TPSC).
It's a central reporting system where safety-related near misses and events are:
- Captured for review
- Risk rated
- Monitored for future continuous improvement

Serious Reportable Events

Events that have serious harm or death consequences to patients, families, staff, or the organization.
They warrant a comprehensive response and the use of additional resources to ensure appropriate action and learning take place.
This category includes Never Events.

Systems Analysis

A Systems analysis looks at the many factors that contributed to a Patient Safety Event.
It yields an understanding of how a system works and how different elements interact.
Adopting a systems approach to harm reduction requires a shift from blaming individuals for errors to analyzing systems to uncover design flaws.
This moves from addressing problems reactively to proactively preventing accidents through system analysis and design.

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Description

Explore the critical concepts of adverse events, clinical risks, and continuous improvement in healthcare. This quiz covers methodologies such as PDSA and DMAIC to enhance patient care quality and safety. Understand the definitions and implications of harm and hazards in the healthcare environment.