37 Questions
What is the primary goal of providing safe healthcare?
To avoid injuries to patients from the care intended to help them
What is the main purpose of providing timely healthcare?
To reduce waits and sometimes unfavorable delays
What is the primary focus of family-centered healthcare?
Providing care that is respectful of patient preferences and values
What is the main goal of providing efficient healthcare?
To avoid waste of equipment, supplies, ideas, and energy
What is the main characteristic of equal healthcare?
Providing care that does not vary in quality due to personal characteristics
What is the primary cause of most errors in healthcare?
System flaws or organizational failures
What is the primary characteristic of latent errors in healthcare?
They arise from system flaws or organizational failures
What is the primary characteristic of active errors in healthcare?
They are committed by frontline staff and tend to have direct patient consequences
What is the recommended dose of adrenaline (epinephrine) in anaphylaxis?
0.3-0.5mg IM
What is the definition of patient safety?
Avoiding harm to patients during healthcare processes
Which approach focuses on the errors of individuals, blaming them?
The human (person) approach
Why do adverse events often occur?
Due to system breakdowns
What is the result of blaming and punishing individuals?
Ineffective approach to improving safety
What can be done to improve patient safety?
Standardizing and simplifying clinical processes
What are the two main categories of system errors in healthcare?
Active errors and latent errors
What is the term for the failure of a system to prevent a potential accident?
Latent error
What is the definition of patient safety according to the World Health Organization (WHO) and World Alliance for Patient Safety?
The absence or reduction of risk of any unnecessary harm to a patient during healthcare
What is the adverse event rate in KKUH (2014) according to the data?
6.2%
Why is patient safety a significant problem?
Because there are more deaths annually due to healthcare than from road accidents, breast cancer, and AIDS combined
What is the main goal of patient safety?
To reduce the risk of harm to a patient during healthcare to an acceptable minimum
Which of the following is a consequence of patient harm?
Increased length of stay (LOS) in healthcare facilities
What is the primary goal of adhering to national Patient Safety Goals and Required Organization Practices (ROP)?
To reduce medical errors and harm
What is the purpose of medication reconciliation in patient safety?
To compare medication orders with the patient's actual medication regimen
In the case study, what was the primary cause of the patient's adverse reaction?
The doctor administered the medication without verification
What is the importance of client/patient verification in patient safety?
To verify the patient's identity
In the case study, what could have prevented the patient's adverse reaction?
The nurse communicating with the doctor
What is the purpose of reporting adverse events in patient safety?
To identify areas for improvement
What is the primary goal of hand hygiene in patient safety?
To reduce the risk of infection
What is the purpose of infusion pumps training in patient safety?
To reduce the risk of medication errors
What is an example of a latent or system error?
Giving the wrong medication
What is the Swiss Cheese Model of Accident Causation?
A theoretical model that illustrates how accidents occur in organizations
What is a patient safety culture?
A pattern of behavior that prioritizes patient safety
What is a characteristic of a blame culture?
Looking for the individual responsible for a mistake
What is the result when the 'holes' in the Swiss Cheese Model align?
An accident occurs
What is an example of an external factor that contributes to latent or system errors?
Inadequate equipment
What is the purpose of the Swiss Cheese Model?
To illustrate how accidents occur in organizations
What is the goal of a patient safety culture?
To minimize patient harm
Study Notes
Patient Safety
- Patient safety is the avoidance, prevention, and amelioration of harm from healthcare providers.
- 1,000,000 injuries/year occur in U.S. hospitals, and 44,000 – 98,000 deaths are caused by medical error/year.
- There are more deaths annually from healthcare than from road accidents, breast cancer, and AIDS combined.
Error and Harm
- Errors in healthcare can be caused by active failures (human errors) or latent conditions (system flaws or organizational failures).
- Most errors are not a result of human error or negligence, but arise from system flaws or organizational failures.
Key Elements of Healthcare Quality
- Safe: Avoiding injuries to patients from the care that is intended to help them.
- Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit.
- Timely: Reducing waits and sometimes unfavorable delays for both those who receive and those who give care.
- Family-Centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values.
- Efficient: Avoiding waste, in particular waste of equipment, supplies, ideas, and energy.
- Equal: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status.
System Errors
- Active (human) errors: committed by frontline staff and tend to have direct patient consequences.
- Latent (system) errors: arise from system flaws or organizational failures, such as understaffed wards, inadequate equipment, and insurance paperwork.
Swiss Cheese Model of Accident Causation
- The system has many holes, some from active (human) failures and others from latent (system) conditions.
- The typical accident occurs because several human errors occur at all levels in the organization in a way that makes the accident unavoidable.
Patient Safety Culture
- An integrated pattern of individual and organizational behavior, based on a system of shared beliefs and values, that determine the organization's commitment to quality and patient safety.
- Two types of responses to mistakes: blame culture and just culture.
Case Study
- A patient receives 1mg of adrenaline IV instead of 0.3-0.5mg IM, which leads to harm.
- Contributing factors to the error: lack of communication, inadequate labeling of syringe, lack of care with potent medication, and not double-checking what it is.
National Patient Safety Goals
- Adhere and follow national patient safety goals/required organization practices (ROP).
- Adverse event reporting, client/patient verification, medication reconciliation, control of concentrated electrolytes, and others.
Assess your knowledge of patient safety, understanding the importance of quality healthcare and how to foster a culture of safety. Learn to differentiate between error and harm, and recognize the characteristics of a just culture.
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