Podcast
Questions and Answers
What is a Never Event?
What is a Never Event?
Which of the following statements is true regarding Near Miss Events?
Which of the following statements is true regarding Near Miss Events?
What can be inferred about Non Safety Events?
What can be inferred about Non Safety Events?
In which category do Never Events fall?
In which category do Never Events fall?
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Which type of Never Event involves surgical or invasive procedures?
Which type of Never Event involves surgical or invasive procedures?
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Why is it important to categorize an incident as a Never Event?
Why is it important to categorize an incident as a Never Event?
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What is a defining characteristic of Never Events?
What is a defining characteristic of Never Events?
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Which of the following is NOT a setting where Never Events can occur?
Which of the following is NOT a setting where Never Events can occur?
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What is the primary goal after a patient safety event occurs?
What is the primary goal after a patient safety event occurs?
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Who is responsible for overseeing the completion of the electronic Safety Event Report?
Who is responsible for overseeing the completion of the electronic Safety Event Report?
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What should be done after a serious patient safety event is reported?
What should be done after a serious patient safety event is reported?
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What role does the Clinical Performance Team have in relation to patient safety events?
What role does the Clinical Performance Team have in relation to patient safety events?
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What should nursing management do when continuous improvement initiatives are developed?
What should nursing management do when continuous improvement initiatives are developed?
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How should feedback on reported events be handled by the Clinical Manager?
How should feedback on reported events be handled by the Clinical Manager?
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What is a key responsibility of the clinical lead within a hospital after a safety-related event?
What is a key responsibility of the clinical lead within a hospital after a safety-related event?
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What is expected during systems analysis of patient safety events?
What is expected during systems analysis of patient safety events?
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What defines an adverse event in healthcare?
What defines an adverse event in healthcare?
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How is clinical risk defined?
How is clinical risk defined?
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What is the purpose of continuous improvement in healthcare?
What is the purpose of continuous improvement in healthcare?
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Which of the following is NOT a methodology used for structured problem solving?
Which of the following is NOT a methodology used for structured problem solving?
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What constitutes harm in medical terms?
What constitutes harm in medical terms?
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What is meant by 'hazard' in a healthcare context?
What is meant by 'hazard' in a healthcare context?
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Which procedure is categorized as an invasive procedure?
Which procedure is categorized as an invasive procedure?
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What marks the start of an invasive procedure?
What marks the start of an invasive procedure?
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What is the deadline for reporting all safety events in the Safety Event Management System?
What is the deadline for reporting all safety events in the Safety Event Management System?
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Who is responsible for completing the AAR and identifying contributing factors after an event is reported?
Who is responsible for completing the AAR and identifying contributing factors after an event is reported?
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When must serious reportable events be reviewed and categorized?
When must serious reportable events be reviewed and categorized?
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What will happen once a safety event is closed?
What will happen once a safety event is closed?
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What is the initial action required from all staff regarding safety events?
What is the initial action required from all staff regarding safety events?
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What can the PSM request if an event is complicated and requires more time?
What can the PSM request if an event is complicated and requires more time?
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How are alerts sent out for serious reportable events?
How are alerts sent out for serious reportable events?
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What is the timeframe for categorizing and finalizing a serious reportable event with the Review Team?
What is the timeframe for categorizing and finalizing a serious reportable event with the Review Team?
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What defines a Never Event in healthcare?
What defines a Never Event in healthcare?
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Which of the following is included in the definition of a surgical/invasive procedure?
Which of the following is included in the definition of a surgical/invasive procedure?
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How is surgery defined in the context of Never Events?
How is surgery defined in the context of Never Events?
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What is the primary responsibility of a surgeon regarding Never Events?
What is the primary responsibility of a surgeon regarding Never Events?
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Which of the following statements about Never Events is correct?
Which of the following statements about Never Events is correct?
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What type of procedure does NOT fall under the Never Events policy?
What type of procedure does NOT fall under the Never Events policy?
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Which of the following best describes the classification of Never Events?
Which of the following best describes the classification of Never Events?
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Which statement accurately reflects the implications of a Never Event?
Which statement accurately reflects the implications of a Never Event?
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The policy includes new definitions pertaining to events including an algorithm to ascertain the type of ______, level of harm, and Serious Reportable Events.
The policy includes new definitions pertaining to events including an algorithm to ascertain the type of ______, level of harm, and Serious Reportable Events.
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The expectation is that the outcomes of analysis should lead to Continuous ______ activities aimed at improving patient safety.
The expectation is that the outcomes of analysis should lead to Continuous ______ activities aimed at improving patient safety.
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Documentation of the processes to be followed for reporting, investigation, and ______ following safety events is included in the policy.
Documentation of the processes to be followed for reporting, investigation, and ______ following safety events is included in the policy.
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Actions to take following a safety event with severe harm or death or a Serious Reportable ______ are addressed in the policy.
Actions to take following a safety event with severe harm or death or a Serious Reportable ______ are addressed in the policy.
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The policy outlines the establishment of event ‘alert’ email groups and escalation flows with specific ______ for completion of safety event reports.
The policy outlines the establishment of event ‘alert’ email groups and escalation flows with specific ______ for completion of safety event reports.
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Study Notes
Adverse Events
- Any event that harms the patient due to an act of commission or omission, and not the patient's condition.
Clinical Risks
- The likelihood that an adverse incident will harm the patient.
Continuous Improvement
- A systematic approach to enhancing the quality of care and outcomes for patients.
Harm
- Any physical or psychological injury or damage to a person's health, including both temporary and permanent injury.
Hazard
- Any source of potential damage, harm, or adverse health effects on patients or healthcare personnel.
Invasive Procedure
- Any surgical intervention, even outside a surgical environment. Examples include pain relief blocks, biopsies, and line insertion.
Invasive Procedure Start Time
- The moment a patient's anatomy is permanently altered, like making the initial incision.
Near Miss
- An event that did not reach the patient due to luck or early detection.
Never Events
- Preventable patient safety incidents that can cause serious harm or death. Examples are grouped into Surgical/Invasive Procedure, Medication, Mental Health, and General.
Non Safety Events
- Events that occur without a direct impact on a patient. These may highlight concerns such as occupational risks or hazards.
Nursing Management (NM, DNM) / Hospital Clinical Manager (HCM)
- Ensures all patient safety related events are identified, reported, and addressed with action plans.
Clinical Performance Team (Corporate Office)
- Reviews clinical outcomes and patient safety event trends to identify national priorities and update the MCSA clinical risk register.
Timeframes for Reporting and Management of Events
- All safety events must be managed to closure within a specific timeframe.
Alerts and Notifications from Safety Event Management System
- All events are automatically processed through a workflow and notifications are sent to relevant stakeholders like unit managers and the hospital governance team.
Rationale for Focusing on Never Events
- They are largely preventable through the implementation of known guidelines and safety recommendations. They have the potential to cause serious harm or death.
Surgical/Invasive Procedure
- Includes all invasive surgical and other procedures, both within and outside a theatre setting. Interventions related to vaginal birth and central line placement in wards are included, while peripheral IV line placement, phlebotomy, and urinary catheter insertion are excluded.
Surgical/Invasive Procedure - Wrong Patient
- An invasive procedure or surgery performed on the wrong patient.
Patient Safety Policy Objectives
- Standardizes definitions and processes for patient safety events.
- Based on Mediclinic Group Framework for Event Management (March 2023).
- Ascertain event type, level of harm, and Serious Reportable Events (including never events).
- Defines roles and responsibilities for event management.
- Outlines reporting, investigation, and escalation processes for safety events.
- Specifies actions for severe harm, death, or Serious Reportable Events.
- Establishes event 'alert' email groups and escalation flows with specific timeframes.
- Emphasizes continuous improvement activities for patient safety.
- Details processes for reporting to the Legal Department and their involvement.
- Includes specific actions for Maternal and neonatal deaths.
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Description
Test your knowledge on patient safety concepts, including adverse events, clinical risks, and harm. This quiz will explore the definitions and implications of various terms such as invasive procedures and never events. Enhance your understanding of systematic approaches to improving healthcare outcomes.