Healthcare Safety, Quality, and Informatics

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Questions and Answers

What is the institute of medicine (IOM)?

an independent nonprofit organization that works outside the federal government to provide unbiased and authoritative advice on health and health care to decision makers and the public

What did the IOM's first report, To Err Is Human, identify?

medical errors as the leading cause of injury and unexpected death in health-care settings in the US

List the eight areas of consumer rights and responsibilities.

  1. information disclosure, 2. choice of providers and plans, 3. choice of health-care providers taht is sufficient to ensure access to appropriate high-quality care, 4. access to emergency services, 5. participation in treatment decisions, 6. respect and nondiscrimination; confidentialty of heatlh invormation, 7. compalints and appeals, 8. consumer responsibilities

What are the six aims for healthcare improvement?

<p>safe, effective, patient-centered, timely, efficient, equitable</p> Signup and view all the answers

What are the five essential competencies for all future health professionals?

<ol> <li>provide patient-centered care, 2. work in interdisciplinary teams, 3. employ evidence-based practice, 4. apply quality improvement, 5. use informatics</li> </ol> Signup and view all the answers

What is patient-centered care?

<p>identify, respect, and care about patients rather than differences, values, preferences and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health</p> Signup and view all the answers

What is advocacy in the context of healthcare?

<p>a process of analyzing, counseling, and responding to patient's care and self-determination preferences</p> Signup and view all the answers

What is empowerment in healthcare?

<p>patient's perceptions of access to information, support, resources, and opportunities to learn and grow that enable them to optimize their health and gain a sense of meaningfulness, self-determination, competency, and impact on their lives</p> Signup and view all the answers

What is self-management in healthcare?

<p>to ensure that the sharing of knowledge between clinicians and patients and their families is maximized, that the patient is recognized as the source of control, and that the tools and systems supports that make self-management tenable is available</p> Signup and view all the answers

What is health literacy?

<p>the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions</p> Signup and view all the answers

What is cultural competence?

<p>the attitudes, knowledge, and skills necessary for providing quality care to diverse populations</p> Signup and view all the answers

What is an optimal healing environment?

<p>supports and stimulates patient healing by addressing the social, psychological, physical, spiritual, and behavioral components of healthcare and enabling the body's capacity to heal itself</p> Signup and view all the answers

What is the major goal of care coordination?

<p>to establish and support a continuous healing relationship, enabled by an integrated clinical environment and characterized by the proactive delivery of evidence-based care and follow-up</p> Signup and view all the answers

What is quality improvement?

<p>a cyclical process designed to monitor and evaluate workflow and work processes</p> Signup and view all the answers

What is informatics in healthcare?

<p>communicate, manage knowledge, mitigate error, and support decision making using information technology -outcomes of care, informaiton management, documentation</p> Signup and view all the answers

What does 'safety' mean in the context of healthcare?

<p>freedom from accidental injury</p> Signup and view all the answers

What is human factors engineering?

<p>science that studies human capabilities and limitations and applies knowledge gleaned to the design of safe, effective processes and systems for humans with the goal of achieving effective, efficient, and safe care</p> Signup and view all the answers

What is reliability science?

<p>the ability of an operation to be failure or defect free over time</p> Signup and view all the answers

What are the five principles necessary for a safe healthcare environment?

<p>-providing leadership -respecting human limits in the design process -promoting effective team functioning -anticipating the unexpected -creating a learning environment</p> Signup and view all the answers

What are the five characteristics of high-reliability organizations?

<ol> <li>sensitivity to operations</li> <li>reluctance to simplify</li> <li>preoccupation with failure</li> <li>deference to expertise</li> <li>resilience</li> </ol> Signup and view all the answers

What is nursing informatics?

<p>specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice</p> Signup and view all the answers

What is the difference between EMR and EHR?

<p>electronic medical record is the record used by a single org, the electronic health record is used by more than one organization and provides info throughout the continuum of care (A)</p> Signup and view all the answers

What are the eight core functions of an EHR?

<ol> <li>health and information data</li> <li>result management</li> <li>order management</li> <li>decision support</li> <li>electronic communications and connectivity</li> <li>patient support</li> <li>administrative processes and reporting</li> <li>reporting and population health</li> </ol> Signup and view all the answers

What is data mining?

<p>the process of extracting specific data or knowledge that was previously unknown</p> Signup and view all the answers

What are decision support systems?

<p>provide warnings or other decision support methods to help health-care professionals become more aware of certain clinical information</p> Signup and view all the answers

What is the purpose of the American Recovery and Reinvestment Act of 2009 (ARRA) regarding informatics?

<p>helped to advance the field of informatics provides incentives when metrics are met by both physician practices and hospitals to move toward electronic documentation and processes to improve patient care</p> Signup and view all the answers

Who are superusers in the context of healthcare informatics?

<p>generally representatives from the local nursing locations who receive enhanced training to help with implementation success and stability over the life of the system</p> Signup and view all the answers

What are key components of safety in healthcare?

<p>-human errors and factors (consciously avoiding acts of omission, and acts of comission) -standardized protocols and practice -safety culture</p> Signup and view all the answers

Briefly describe the types of medical errors.

<p>-adverse event or pt safety event: occurs when an injury to a pt is caused by medical management rather than the pt's underlying condition -error of omission: results when an action that is a standard of care is not taken or omitted -error of commission: results when the wrong action is taken or committed -unsafe act: occurs in the presence of a potential hazard, sometimes as the result of a violation, not an error -slips, lapses, and mistakes: refer to actions that do not result in the intended outcome -near miss: is a potential error that was discovered before it was carried out -sentinel event: refers to a pt safety event that results in death, permanent harm, or severe temporary harm and intervention required to sustain life</p> Signup and view all the answers

What are common causes of medical errors?

<p>-human factors: include staffing levels, staff education and competency, and staffing shortages -communication: include intraprofessional and interprofessional communication and interactions with pts and their families -leadership: include leadership and management at all levels, organizational structure, policies and procedures, and practice guidelines</p> Signup and view all the answers

Describe what should be included in incident reports.

<p>-person who observed the incident or was first on the scene should initiate the report -include the pt's account -document only the facts -include other health care professionals who observed event and have them cosign -have the injured pt or individual seen by a health-care provider, if appropriate -do not indicate the health-care record that an incident report was completed -forward the incident report to departments as required by organizational policies -minimize the number of copies of the incident report to maintain confidentiality</p> Signup and view all the answers

What are the three stages of culture safety?

<p>-safety management is based on rules and regulations -good safety performance becomes an organizational goal -safety performance is seen as dynamic and continuously improving</p> Signup and view all the answers

What is just culture in healthcare?

<p>-part of a culture of safety -refers to a culture that is fair to those who make an error -improves pt safety bc it encourages nurses to learn from each other's mistakes and to report all errors and near misses w/o fear of repercussions -requires responsibility for one's own actions and constructive feedback provided to peers</p> Signup and view all the answers

Describe the difference between automatic actions and standardizations.

<p>-automatic actions: when cognitive adaptive mechanisms kick in, resulting in auto pilot -standardization: process of developing and implementing uniform criteria, methods, processes, designs, or practices</p> Signup and view all the answers

List the four key principles of quality improvement (QI).

<ol> <li>QI works as systems and processes.</li> <li>There is a focus on patients.</li> <li>There is a focus on being part of the team.</li> <li>There is a focus on the use of data.</li> </ol> Signup and view all the answers

What is the significance of 'To Err Is Human'?

<p>IOM's first report which identified medical errors as the leading cause of injury and unexpected death in health-care settings in the US.</p> Signup and view all the answers

List the eight areas of consumer rights and responsibilities in healthcare.

<ol> <li>Information disclosure, 2. Choice of providers and plans, 3. Choice of health-care providers that is sufficient to ensure access to appropriate high-quality care, 4. Access to emergency services, 5. Participation in treatment decisions, 6. Respect and nondiscrimination; confidentiality of health information, 7. Complaints and appeals, 8. Consumer responsibilities.</li> </ol> Signup and view all the answers

Define patient-centered care.

<p>Identify, respect, and care about patients' differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health.</p> Signup and view all the answers

Define advocacy in healthcare.

<p>A process of analyzing, counseling, and responding to patient's care and self-determination preferences.</p> Signup and view all the answers

Define empowerment in the context of patient care.

<p>Patient's perceptions of access to information, support, resources, and opportunities to learn and grow that enable them to optimize their health and gain a sense of meaningfulness, self-determination, competency, and impact on their lives.</p> Signup and view all the answers

Define health literacy.

<p>The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.</p> Signup and view all the answers

What does cultural competence mean in healthcare?

<p>The attitudes, knowledge, and skills necessary for providing quality care to diverse populations.</p> Signup and view all the answers

Define optimal healing environment.

<p>Supports and stimulates patient healing by addressing the social, psychological, physical, spiritual, and behavioral components of healthcare and enabling the body's capacity to heal itself.</p> Signup and view all the answers

Define quality improvement (QI) in healthcare.

<p>A cyclical process designed to monitor and evaluate workflow and work processes.</p> Signup and view all the answers

What is the role of informatics in healthcare?

<p>Communicate, manage knowledge, mitigate error, and support decision making using information technology; outcomes of care, information management, documentation.</p> Signup and view all the answers

Define safety in the context of healthcare.

<p>Freedom from accidental injury.</p> Signup and view all the answers

Define reliability science.

<p>The ability of an operation to be failure or defect free over time.</p> Signup and view all the answers

List five principles necessary for a safe healthcare environment.

<p>Providing leadership, respecting human limits in the design process, promoting effective team functioning, anticipating the unexpected, creating a learning environment.</p> Signup and view all the answers

What is the difference between an EMR and an EHR?

<p>An electronic medical record (EMR) is the record used by a single organization, while the electronic health record (EHR) is used by more than one organization and provides info throughout the continuum of care.</p> Signup and view all the answers

List eight core functions of an EHR.

<ol> <li>Health and information data, 2. Result management, 3. Order management, 4. Decision support, 5. Electronic communications and connectivity, 6. Patient support, 7. Administrative processes and reporting, 8. Reporting and population health.</li> </ol> Signup and view all the answers

Define data mining.

<p>The process of extracting specific data or knowledge that was previously unknown.</p> Signup and view all the answers

What is the significance of the American Recovery and Reinvestment Act of 2009 (ARRA) in healthcare informatics?

<p>Helped to advance the field of informatics; provides incentives when metrics are met by both physician practices and hospitals to move toward electronic documentation and processes to improve patient care.</p> Signup and view all the answers

Who are superusers in the context of EHR implementation?

<p>Generally representatives from the local nursing locations who receive enhanced training to help with implementation success and stability over the life of the system.</p> Signup and view all the answers

List different types of medical errors.

<p>-Adverse event or pt safety event: occurs when an injury to a pt is caused by medical management rather than the pt's underlying condition -error of omission: results when an action that is a standard of care is not taken or omitted -error of commission: results when the wrong action is taken or committed -unsafe act: occurs in the presence of a potential hazard, sometimes as the result of a violation, not an error -slips, lapses, and mistakes: refer to actions that do not result in the intended outcome -near miss: is a potential error that was discovered before it was carried out -sentinel event: refers to a pt safety event that results in death, permanent harm, or severe temporary harm and intervention required to sustain life</p> Signup and view all the answers

Who should initiate an incident report?

<p>Person who observed the incident or was first on the scene.</p> Signup and view all the answers

Describe the three stages of a culture of safety.

<p>-Safety management is based on rules and regulations -Good safety performance becomes an organizational goal -Safety performance is seen as dynamic and continuously improving</p> Signup and view all the answers

What is a just culture?

<p>Refers to a culture that is fair to those who make an error. Improves patient safety because it encourages nurses to learn from each other's mistakes and to report all errors and near misses without fear of repercussions. Requires responsibility for one's own actions and constructive feedback provided to peers.</p> Signup and view all the answers

What is the difference between automatic actions and standardization?

<p>Automatic actions: when cognitive adaptive mechanisms kick in, resulting in autopilot. Standardization: process of developing and implementing uniform criteria, methods, processes, designs, or practices.</p> Signup and view all the answers

What are the 4 key principles of quality improvement?

<ol> <li>QI works as systems and processes. 2. There is a focus on patients. 3. There is a focus on being part of the team. 4. There is a focus on the use of data.</li> </ol> Signup and view all the answers

What are the steps of the quality improvement process?

<p>No answer provided in text.</p> Signup and view all the answers

What are quality improvement tools?

<p>No answer provided in text.</p> Signup and view all the answers

What is the significance of the IOM report 'To Err Is Human'?

<p>It identified medical errors as the leading cause of injury and unexpected death in health-care settings in the US.</p> Signup and view all the answers

Define advocacy in the context of patient care.

<p>A process of analyzing, counseling, and responding to patient's care and self-determination preferences.</p> Signup and view all the answers

What is meant by self-management in healthcare?

<p>To ensure that the sharing of knowledge between clinicians and patients and their families is maximized, that the patient is recognized as the source of control, and that the tools and systems supports that make self-management tenable is available.</p> Signup and view all the answers

What is cultural competence in healthcare?

<p>The attitudes, knowledge, and skills necessary for providing quality care to diverse populations.</p> Signup and view all the answers

Define quality improvement.

<p>A cyclical process designed to monitor and evaluate workflow and work processes.</p> Signup and view all the answers

Define informatics in the context of healthcare.

<p>Communicate, manage knowledge, mitigate error, and support decision making using information technology; outcomes of care, informaiton management, documentation.</p> Signup and view all the answers

What is safety in healthcare?

<p>Freedom from accidental injury.</p> Signup and view all the answers

Define nursing informatics.

<p>Specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.</p> Signup and view all the answers

What is the significance of the American Recovery and Reinvestment Act of 2009 (ARRA) in the context of informatics?

<p>Helped to advance the field of informatics; provides incentives when metrics are met by both physician practices and hospitals to move toward electronic documentation and processes to improve patient care.</p> Signup and view all the answers

Describe what the different types of medical errors are.

<p>-adverse event or pt safety event: occurs when an injury to a pt is caused by medical management rather than the pt's underlying condition -error of omission: results when an action that is a standard of care is not taken or omitted -error of commission: results when the wrong action is taken or committed -unsafe act: occurs in the presence of a potential hazard, sometimes as the result of a violation, not an error -slips, lapses, and mistakes: refer to actions that do not result in the intended outcome -near miss: is a potential error that was discovered before it was carried out -sentinel event: refers to a pt safety event that results in death, permanent harm, or severe temporary harm and intervention required to sustain life</p> Signup and view all the answers

List common causes of medical errors.

<p>-human factors: include staffing levels, staff education and competency, and staffing shortages -communication: include intraprofessional and interprofessional communication and interactions with pts and their families -leadership: include leadership and management at all levels, organizational structure, policies and procedures, and practice guidelines</p> Signup and view all the answers

What guidelines should be followed when completing incident reports?

<p>-person who observed the incident or was first on the scene should initiate the report -include the pt's account -document only the facts -include other health care professionals who observed event and have them cosign -have the injured pt or individual seen by a health-care provider, if appropriate -do not indicate the health-care record that an incident report was completed -forward the incident report to departments as required by organizational policies -minimize the number of copies of the incident report to maintain confidentiality</p> Signup and view all the answers

Define just culture.

<p>-part of a culture of safety -refers to a culture that is fair to those who make an error -improves pt safety bc it encourages nurses to learn from each other's mistakes and to report all errors and near misses w/o fear of repercussions -requires responsibility for one's own actions and constructive feedback provided to peers</p> Signup and view all the answers

Describe the difference automatic actions versus standardization

<p>-automatic actions: when cognitive adaptive mechanisms kick in, resulting in auto pilot -standardization: process of developing and implementing uniform criteria, methods, processes, designs, or practices</p> Signup and view all the answers

List four key principles of quality improvement.

<ol> <li>QI works as systems and processes.</li> <li>There is a focus on patients.</li> <li>There is a focus on being part of the team.</li> <li>There is a focus on the use of data.</li> </ol> Signup and view all the answers

Flashcards

Institute of Medicine (IOM)

An independent nonprofit organization providing unbiased advice on health and healthcare to decision-makers and the public.

To Err Is Human

IOM report that identified medical errors as a leading cause of injury and unexpected death in healthcare.

Consumer Rights and Responsibilities

Eight rights covering information, choice, access, participation, respect, confidentiality, complaints, and responsibilities.

Six Aims for Healthcare Improvement

Six aims for healthcare identified by the IOM: Safe, Effective, Patient-Centered, Timely, Efficient, Equitable.

Signup and view all the flashcards

Five Essential Competencies

Five core abilities: Patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, informatics.

Signup and view all the flashcards

Patient-Centered Care

Care that respects individual patient differences, values, preferences, needs, and ensures coordination and advocacy.

Signup and view all the flashcards

Advocacy

Analyzing, counseling, and responding to patient preferences regarding care and self-determination.

Signup and view all the flashcards

Empowerment

Patient's perception of access to resources and opportunities that enable them to optimize their health.

Signup and view all the flashcards

Self-Management

Sharing knowledge between clinicians and patients, recognizing patient control and support systems.

Signup and view all the flashcards

Health Literacy

Ability to obtain, process, and understand basic health information to make appropriate health decisions.

Signup and view all the flashcards

Cultural Competence

Attitudes, knowledge, and skills for providing quality care to diverse populations.

Signup and view all the flashcards

Optimal Healing Environment

Environment that supports patient healing by addressing social, psychological, physical, spiritual, and behavioral components.

Signup and view all the flashcards

Major Goal of Care Coordination

To establish and support a continuous healing relationship through integrated clinical environments and evidence-based care.

Signup and view all the flashcards

Quality Improvement

A cyclical process designed to monitor and evaluate workflow and work processes for improvement.

Signup and view all the flashcards

Informatics

Using information technology to communicate, manage knowledge, mitigate error, and support decision-making.

Signup and view all the flashcards

Safety

Freedom from accidental injury.

Signup and view all the flashcards

Human Factors Engineering

Applying knowledge of human capabilities and limitations to design safe and effective processes and systems.

Signup and view all the flashcards

Reliability Science

The ability of an operation to be failure or defect free over time.

Signup and view all the flashcards

Five Principles for Safe Healthcare

Leadership, respect for limits, team functioning, anticipating the unexpected, and creating a learning environment.

Signup and view all the flashcards

High-Reliability Organizations (Characteristics)

Sensitivity to operations, reluctance to simplify, preoccupation with failure, deference to expertise, resilience.

Signup and view all the flashcards

Nursing Informatics

Integration of nursing, computer, and information science to manage and communicate data and knowledge.

Signup and view all the flashcards

EMR vs. EHR

EMR is used by a single org, EHR is used across multiple organizations for continuous care.

Signup and view all the flashcards

EHR Core Functions

Data, result, order, decision, communication, patient, administrative, and population health management.

Signup and view all the flashcards

Data Mining

Extracting specific, previously unknown data or knowledge.

Signup and view all the flashcards

Decision Support Systems

Warnings or support methods to help healthcare professionals make informed decisions.

Signup and view all the flashcards

American Recovery and Reinvestment Act (ARRA)

Act that advanced informatics and provided incentives for electronic documentation to improve patient care.

Signup and view all the flashcards

Superusers

Local nursing representatives who receive enhanced training to assist with system implementation and stability.

Signup and view all the flashcards

Parts of Safety

Human factors, standardized protocols, and safety culture.

Signup and view all the flashcards

Types of Medical Errors

Adverse event, errors of omission/commission, unsafe acts, slips/lapses/mistakes, near miss, sentinel event.

Signup and view all the flashcards

Common Causes of Medical Errors

Human factors, communication and leadership.

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Incident Report

Detailed report of an unusual occurrence.

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Culture of Safety Stages

From rules-based to performance-based to dynamic improvement.

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Just Culture

Culture that is fair to those who make an error, encouraging reporting and learning from mistakes.

Signup and view all the flashcards

Automatic Actions vs. Standardization

Auto pilot versus uniform criteria/methods/processes.

Signup and view all the flashcards

Key Principles of Quality Improvement

QI works as systems, focuses on patients and teamwork, and uses data.

Signup and view all the flashcards

Steps of the Quality Improvement Process

No Definition Provided

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Quality Improvement Tools

No Definition Provided

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Study Notes

  • These notes cover key terms and concepts related to safety, quality improvement, and informatics in healthcare
  • Definitions, principles, and characteristics are listed in an easy-to-understand format
  • Important distinctions, such as EMR vs EHR, are highlighted

Institute of Medicine (IOM)

  • An independent nonprofit organization
  • Provides unbiased advice on health and healthcare to decision-makers and the public

To Err Is Human

  • IOM report that identified medical errors as a leading cause of injury and unexpected death in US healthcare settings

Consumer Rights and Responsibilities (Eight Areas)

  • Information disclosure
  • Choice of providers and plans
  • Access to sufficient high-quality healthcare providers
  • Access to emergency services
  • Participation in treatment decisions
  • Respect, nondiscrimination, and confidentiality
  • Complaints and appeals processes
  • Consumer responsibilities

Six Aims for Healthcare Improvement

  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient
  • Equitable

Five Essential Competencies for Health Professionals

  • Provide patient-centered care
  • Work in interdisciplinary teams
  • Employ evidence-based practice
  • Apply quality improvement
  • Use informatics

Patient-Centered Care

  • Focuses on individual patient needs, values, and preferences
  • Includes pain relief, care coordination, clear communication, shared decision-making, and promotion of healthy lifestyles

Advocacy

  • Analyzing, counseling, and responding to patient care and self-determination preferences

Empowerment

  • Patient perceptions of access to information, support, resources, and opportunities to optimize health

Self-Management

  • Maximizing knowledge sharing between clinicians and patients
  • Recognizing the patient's control and providing necessary support systems

Health Literacy

  • The degree to which individuals can obtain, process, and understand basic health information to make appropriate decisions

Cultural Competence

  • Attitudes, knowledge, and skills necessary for providing quality care to diverse populations

Optimal Healing Environment

  • Supports healing by addressing social, psychological, physical, spiritual, and behavioral components of healthcare

Care Coordination Goal

  • Establish and support a continuous healing relationship through proactive, evidence-based care and follow-up

Quality Improvement

  • A cyclical process for monitoring and evaluating workflow and work processes

Informatics

  • Using information technology to communicate, manage knowledge, mitigate error, and support decision-making

Safety

  • Freedom from accidental injury

Human Factors Engineering

  • Designing safe, effective processes and systems based on human capabilities and limitations

Reliability Science

  • Ability of an operation to be failure or defect-free over time

Five Principles for a Safe Healthcare Environment

  • Providing leadership
  • Respecting human limits in design
  • Promoting effective teamwork
  • Anticipating the unexpected
  • Creating a learning environment

High-Reliability Organizations (Five Characteristics)

  • Sensitivity to operations
  • Reluctance to simplify
  • Preoccupation with failure
  • Deference to expertise
  • Resilience

Nursing Informatics

  • Integrates nursing science, computer science, and information science

EMR vs EHR

  • EMR is used by a single organization
  • EHR is used across multiple organizations

EHR Core Functions (Eight)

  • Health information and data
  • Result management
  • Order management
  • Decision support
  • Electronic communication
  • Patient support
  • Administrative processes
  • Reporting and population health

Data Mining

  • Extracting previously unknown data or knowledge

Decision Support Systems

  • Providing warnings and support to enhance awareness of clinical information

American Recovery and Reinvestment Act of 2009 (ARRA)

  • Advanced informatics by providing incentives for using electronic documentation to improve patient care

Superusers

  • Representatives from nursing locations who receive enhanced training to help w/ system implementation

Parts of Safety

  • Human errors and factors
  • Standardized protocols and practice
  • Safety culture

Types of Medical Errors

  • Adverse event: Injury caused by medical management
  • Error of omission: Standard of care not taken
  • Error of commission: Wrong action taken
  • Unsafe act: Potential hazard present
  • Slips, lapses, mistakes: Actions not resulting in intended outcome
  • Near miss: Potential error discovered before being carried out
  • Sentinel event: Results in death, permanent harm, or severe temporary harm

Common Causes of Medical Errors

  • Human factors: staffing levels, education, competency, shortages
  • Communication: intra- and inter-professional, patient and family interactions
  • Leadership: organizational structure, policies, and practice guidelines

Incident Reports

  • Observed or first on the scene should initiate report
  • Include patient's account and facts, other health care professions who observed the event should initial
  • Have injured individual seen by health-care provider, if appropriate
  • Do not indicate in health record that incident report was completed
  • Minimal copies of incident to maintain confidentiality

Culture of Safety (Three Stages)

  • Safety management based on rules
  • Good safety performance as organizational goal
  • Safety performance as dynamic and continuously improving

Just Culture

  • Fair to those who make errors
  • Encourages reporting without fear of repercussions
  • Requires responsibility and constructive feedback

Automatic Actions vs. Standardization

  • Automatic Actions: Cognitive adaptive mechanisms leading to auto pilot
  • Standardization: Uniform criteria, methods, processes, and practices

Quality Improvement Principles (Four)

  • QI works as systems and processes
  • Focus on patients
  • Focus on teamwork
  • Focus on data

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