Patient Safety and Risk Management

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Questions and Answers

What is a Never Event?

An event that has occurred in only one healthcare setting.

An event that is reported but does not require action.

An event that always results in patient harm.

An event that is preventable through known guidelines. (correct)

Which of the following statements is true regarding Near Miss Events?

They are considered Never Events.

They always result in significant patient harm.

They are a type of Non Safety Event.

They did not reach the patient due to luck or early detection. (correct)

What can be inferred about Non Safety Events?

They have no impact on healthcare practices.

They always lead to direct patient harm.

They are classified as Never Events.

They may indicate other concerns unrelated to patient safety. (correct)

In which category do Never Events fall?

Serious Reportable Events. Signup and view all the answers

Which type of Never Event involves surgical or invasive procedures?

Surgical/invasive procedure events. Signup and view all the answers

Why is it important to categorize an incident as a Never Event?

To prevent future occurrences of similar incidents. Signup and view all the answers

What is a defining characteristic of Never Events?

They have been supported by past evidence of occurrence. Signup and view all the answers

Which of the following is NOT a setting where Never Events can occur?

Routine administrative tasks. Signup and view all the answers

What is the primary goal after a patient safety event occurs?

To prevent further harm to the patient Signup and view all the answers

Who is responsible for overseeing the completion of the electronic Safety Event Report?

The clinical lead and nursing management Signup and view all the answers

What should be done after a serious patient safety event is reported?

Perform an After Action Review to capture learning Signup and view all the answers

What role does the Clinical Performance Team have in relation to patient safety events?

They review clinical outcome and safety event trends Signup and view all the answers

What should nursing management do when continuous improvement initiatives are developed?

Support staff to implement the improvements Signup and view all the answers

How should feedback on reported events be handled by the Clinical Manager?

Feedback should be used to develop further training Signup and view all the answers

What is a key responsibility of the clinical lead within a hospital after a safety-related event?

Ensure action plans for reported events are developed and implemented Signup and view all the answers

What is expected during systems analysis of patient safety events?

To include members from various hospital teams in investigations Signup and view all the answers

What defines an adverse event in healthcare?

An event resulting from the healthcare provider's actions causing unintended harm. Signup and view all the answers

How is clinical risk defined?

The likelihood of an adverse incident causing injury or harm. Signup and view all the answers

What is the purpose of continuous improvement in healthcare?

To enhance the quality of care and patient outcomes through systematic methods. Signup and view all the answers

Which of the following is NOT a methodology used for structured problem solving?

SWOT analysis Signup and view all the answers

What constitutes harm in medical terms?

Both physical and psychological injuries, whether temporary or permanent. Signup and view all the answers

What is meant by 'hazard' in a healthcare context?

A situation that could potentially endanger patient safety. Signup and view all the answers

Which procedure is categorized as an invasive procedure?

A tooth extraction. Signup and view all the answers

What marks the start of an invasive procedure?

When the patient's anatomy begins to be permanently altered. Signup and view all the answers

What is the deadline for reporting all safety events in the Safety Event Management System?

By the 7th of the next month Signup and view all the answers

Who is responsible for completing the AAR and identifying contributing factors after an event is reported?

Unit manager Signup and view all the answers

When must serious reportable events be reviewed and categorized?

Within 10 working days Signup and view all the answers

What will happen once a safety event is closed?

The Hospital Governance Team will receive the final report Signup and view all the answers

What is the initial action required from all staff regarding safety events?

Report a safety event Signup and view all the answers

What can the PSM request if an event is complicated and requires more time?

Time extension from the RCM Signup and view all the answers

How are alerts sent out for serious reportable events?

At the time of event loading in the system Signup and view all the answers

What is the timeframe for categorizing and finalizing a serious reportable event with the Review Team?

Within 15 working days Signup and view all the answers

What defines a Never Event in healthcare?

An incident that is preventable through known safety guidelines. Signup and view all the answers

Which of the following is included in the definition of a surgical/invasive procedure?

Cardiology interventions. Signup and view all the answers

How is surgery defined in the context of Never Events?

An invasive procedure that involves skin incision or instrument insertion. Signup and view all the answers

What is the primary responsibility of a surgeon regarding Never Events?

To manage the surgical outcome and prevent incidents. Signup and view all the answers

Which of the following statements about Never Events is correct?

Evidence indicates that Never Events have occurred in the past. Signup and view all the answers

What type of procedure does NOT fall under the Never Events policy?

Central line placements in ward areas. Signup and view all the answers

Which of the following best describes the classification of Never Events?

Never Events can occur in various healthcare settings. Signup and view all the answers

Which statement accurately reflects the implications of a Never Event?

Preventative measures are crucial to avert future Never Events. Signup and view all the answers

The policy includes new definitions pertaining to events including an algorithm to ascertain the type of ______, level of harm, and Serious Reportable Events.

Event Signup and view all the answers

The expectation is that the outcomes of analysis should lead to Continuous ______ activities aimed at improving patient safety.

Improvement Signup and view all the answers

Documentation of the processes to be followed for reporting, investigation, and ______ following safety events is included in the policy.

Escalation Signup and view all the answers

Actions to take following a safety event with severe harm or death or a Serious Reportable ______ are addressed in the policy.

Event Signup and view all the answers

The policy outlines the establishment of event ‘alert’ email groups and escalation flows with specific ______ for completion of safety event reports.

Timeframes Signup and view all the answers

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.