Mitigating risk in the surgical setting ppt

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Questions and Answers

What type of human error is identified as the primary cause of medical errors?

Action-based errors

Cognitive errors

Technical errors

Communication-based errors (correct)

Which system of thinking is characterized by fast, automatic responses and unconscious pattern recognition?

Cognitive reasoning

System I thinking (correct)

System II thinking

Explicit bias

In the context of surgical errors, which type of malpractice claim is most commonly reported in hospitals?

Medication errors

Surgical errors (correct)

Technical failures

Missed diagnosis

The SBAR communication technique is primarily used for which purpose in patient care?

Effective handoffs among healthcare providers Signup and view all the answers

Which error type is often the result of missed opportunities for action or decision-making in healthcare?

Cognitive errors Signup and view all the answers

What is the purpose of the WHO Surgery Checklist?

To ensure essential safety protocols are followed during surgery Signup and view all the answers

What does the acronym CUS stand for in the context of medical communication?

Concerned, Uncomfortable, and Safety issue Signup and view all the answers

Which of the following is NOT a characteristic of System II thinking?

Automatic responses Signup and view all the answers

Which of the following is categorized as a 'never event'?

Retained surgical instruments Signup and view all the answers

What is a key factor in risk stratification by the surgical team before a procedure?

Patient's past medical and surgical history Signup and view all the answers

Which practice is essential in avoiding the risk of wrong-site surgery?

Surgeon marking the site with the patient present Signup and view all the answers

What is a common pre-operative measure to reduce the risk of infection?

Administering pre-op antibiotics Signup and view all the answers

Which of the following represents a surgical complication indicated by AHRQ patient safety indicators?

Postoperative wound dehiscence Signup and view all the answers

Which of the following is a recommended practice for ensuring patient safety at the surgical site?

Conducting a complete chart review Signup and view all the answers

Which action best represents proper handoff in surgical care?

Using the I PASS the Baton method Signup and view all the answers

What is an important consideration for patients on anticoagulants before surgery?

Days since last dosage Signup and view all the answers

Which of the following conditions requires special risk assessment by the surgical team?

Uncontrolled blood sugar over 300 Signup and view all the answers

What does the WHO surgical checklist emphasize for patient safety?

Clearly defined roles and responsibilities Signup and view all the answers

Which of the following is NOT a focus during postoperative monitoring?

Scheduling the next surgery Signup and view all the answers

What is a primary role of the surgical team during the pre-operative phase?

Evaluating and optimizing patient risks Signup and view all the answers

What type of patient is at an increased risk of intraoperative complications?

A patient with renal insufficiency Signup and view all the answers

Which of the following errors involves a serious oversight that is classified under patient safety indicators?

Accidental puncture and laceration Signup and view all the answers

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.