Podcast
Questions and Answers
What type of human error is identified as the primary cause of medical errors?
Which system of thinking is characterized by fast, automatic responses and unconscious pattern recognition?
In the context of surgical errors, which type of malpractice claim is most commonly reported in hospitals?
The SBAR communication technique is primarily used for which purpose in patient care?
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Which error type is often the result of missed opportunities for action or decision-making in healthcare?
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What is the purpose of the WHO Surgery Checklist?
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What does the acronym CUS stand for in the context of medical communication?
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Which of the following is NOT a characteristic of System II thinking?
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Which of the following is categorized as a 'never event'?
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What is a key factor in risk stratification by the surgical team before a procedure?
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Which practice is essential in avoiding the risk of wrong-site surgery?
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What is a common pre-operative measure to reduce the risk of infection?
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Which of the following represents a surgical complication indicated by AHRQ patient safety indicators?
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Which of the following is a recommended practice for ensuring patient safety at the surgical site?
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Which action best represents proper handoff in surgical care?
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What is an important consideration for patients on anticoagulants before surgery?
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Which of the following conditions requires special risk assessment by the surgical team?
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What does the WHO surgical checklist emphasize for patient safety?
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Which of the following is NOT a focus during postoperative monitoring?
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What is a primary role of the surgical team during the pre-operative phase?
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What type of patient is at an increased risk of intraoperative complications?
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Which of the following errors involves a serious oversight that is classified under patient safety indicators?
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Study Notes
Incidence and Impact of Medical Errors
- Medical errors encompass surgical, diagnostic, medication, devices and equipment failures, infections, falls, and technology-related issues.
- Surgical errors account for the majority of malpractice claims in hospitals, while missed diagnoses dominate claims in outpatient settings.
Types of Human Error
- Communication errors rank as the leading cause of medical errors, often leading to incorrect medication dosages.
- Cognitive errors involve lapses in judgment and decision-making, influenced by implicit and explicit biases.
- System I errors are impulsive and automatic, while System II errors are deliberate and judgment-based, potentially resulting in misdiagnosis or incorrect treatments.
Initiatives to Address Human Error
- Effective communication strategies such as SBAR (situation, background, assessment, recommendation) and closed-loop communication are essential.
- Handoffs are vital for ensuring continuous patient care, promoting clarity in communication.
- Cognitive safety measures include competency-based education and structured onboarding for healthcare professionals.
- Technical strategies incorporate checklists like the WHO Surgery Checklist to enhance procedural safety.
Never Events
- Key examples of never events include wrong-site surgeries, retained surgical instruments, medication errors, surgical site infections (SSIs), and anesthesia-related complications.
- Deaths categorized as never events typically occur in previously healthy patients during or immediately after surgery.
AHRQ Patient Safety Indicators
- Focus on provider-level complications, such as anesthesia complications, postoperative sepsis, and failure to recognize emergencies.
- Include area-level indicators like foreign body retention during procedures and postoperative wound dehiscence.
Risk Mitigation Through Perioperative Optimization
- Pre-operative assessments should address any medications, patient education, and surgical team readiness.
- Managing factors like uncontrolled blood sugar and patient's medical histories (e.g., A-fib, renal insufficiency) is crucial for reducing surgery risks.
- Pre-operative teaching includes instructions regarding recent meals and medication management to reduce infection risks.
Risk Mitigation Strategies in Surgical Settings
- Pre-operative risk mitigation involves chart verification, signed informed consent, allergy checks, and medication reconciliation.
- The surgical team conducts thorough assessments, lab evaluations, and site markings prior to surgery.
- Post-operative care emphasizes monitoring vital signs, pain management, and early detection of complications like hemorrhage or shock.
Effective Handoffs and Communication
- Utilize structured communication frameworks like “I PASS” for effective patient information transfer during nurse and provider handoffs.
- Importance of thorough checks during sign-out processes between surgical teams and nursing staff, ensuring patient safety through shared accountability.
Prevention of Never Events
- Key preventive strategies include patient verification (name, DOB, wristband) to avoid wrong patient incidences.
- Site verification requires thorough checks, including mapping and initialing the correct area pre-surgery.
- To prevent retention of foreign objects, strict counting protocols for surgical instruments are essential before and after procedures.
WHO Surgical Checklist
- The checklist fosters shared accountability, ensuring all stakeholders confirm patient identity, site, procedure, and equipment readiness.
- Incorporates pre-operative antibiotic administration to minimize infection risks and enhance overall surgical safety.
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Description
Explore the various types of medical errors, including surgical, diagnostic, and communication errors. Understand the impact of human behavior and cognitive biases on patient safety, and discover initiatives aimed at reducing these errors in healthcare settings.
