Patient Safety Lecture 1

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Questions and Answers

What is patient safety primarily concerned with?

The absence of unnecessary harm to a patient during healthcare (correct)

Reducing waits for patients and caregivers

Avoiding underuse and overuse of healthcare services

Providing efficient care to minimize waste

What is the approximate annual death toll due to healthcare in comparison to other causes?

Less than road accidents, but more than breast cancer

More than road accidents, but less than breast cancer

Equal to road accidents, but less than breast cancer

More than road accidents, breast cancer, and AIDS combined (correct)

Which of the following is NOT one of the 6 key dimensions of healthcare quality?

Effective

Equal

Family-centered

Economical (correct)

What type of errors are committed by frontline staff with direct patient consequences?

Active errors Signup and view all the answers

What is the primary cause of most errors in healthcare?

System flaws or organizational failures Signup and view all the answers

Which dimension of healthcare quality focuses on reducing waste?

Efficient Signup and view all the answers

What is the primary goal of 'Family-centered' care?

Providing care that is respectful of patient preferences Signup and view all the answers

What type of errors occur due to external forces and indirect failures?

Latent errors Signup and view all the answers

What is included in the definition of serious injury?

Loss of limb or function Signup and view all the answers

What is an adverse drug reaction?

A response to a drug that is noxious and unintended Signup and view all the answers

What is a near miss?

A situation that might have resulted in harm, but did not Signup and view all the answers

How can safety be maintained in clinical incidents?

By adhering to national patient safety goals Signup and view all the answers

What is the importance of human factors in healthcare?

It is a major contributor to adverse events in healthcare Signup and view all the answers

What is the purpose of human factors design in healthcare?

To minimize the likelihood of error or its consequences Signup and view all the answers

What is an example of a trap in healthcare?

Look-alike and sound-alike medications Signup and view all the answers

What is the focus of human factors design in healthcare?

The entire range of healthcare workers Signup and view all the answers

What is a major flaw in the traditional approach to problems in healthcare?

It blames and shames healthcare professionals Signup and view all the answers

What is a consequence of operating in a culture of blame in healthcare?

The organization will have great difficulty in learning from errors Signup and view all the answers

What is a key aspect of a systems approach to healthcare?

Looking at healthcare as a whole system with its complexity and interdependence Signup and view all the answers

Why do healthcare professionals hesitate to report incidents or errors?

They are afraid of being blamed and shamed Signup and view all the answers

What is the purpose of accountability in healthcare?

To demonstrate professional behavior to the public and colleagues Signup and view all the answers

What is a characteristic of a healthcare professional involved in an adverse event or error?

They are usually destroyed and become the 'second victim' Signup and view all the answers

What is a consequence of a systems approach to healthcare?

It decreases the chance of future adverse incidents Signup and view all the answers

What is a factor that contributes to the complexity of healthcare systems?

Huge number of relationships between healthcare professionals Signup and view all the answers

What is the primary role of administration in an organization?

To oversee the overall function and management of the organization Signup and view all the answers

What is the primary goal of the forming stage of team development?

To select the best candidates for a team Signup and view all the answers

What is a characteristic of the storming stage of team development?

Team members hesitate to express new ideas and opinions Signup and view all the answers

What is a characteristic of the norming stage of team development?

Team members work together to overcome personal disagreements Signup and view all the answers

What is a characteristic of the performing stage of team development?

Team members are capable of dealing with any task based on their strengths and weaknesses Signup and view all the answers

How can team members move from the storming stage to the norming stage?

By introducing team members to each other in more detail Signup and view all the answers

What is a characteristic of successful teams?

Team members have measurable goals Signup and view all the answers

What is essential for successful teams?

Mutual respect among team members Signup and view all the answers

What is the primary focus of risk management in healthcare?

Improving organizational and client safety Signup and view all the answers

What is a hazard, in the context of healthcare?

Any activity, situation, or substance that has the potential to cause harm Signup and view all the answers

What is the purpose of mentally rehearsing complex procedures?

To prepare for potential errors and complications Signup and view all the answers

What is the definition of health, according to the World Health Organization?

A state of complete physical, mental, and social well-being Signup and view all the answers

What is the main benefit of building checks into routine tasks?

To reduce the risk of errors Signup and view all the answers

What is the primary goal of risk management in healthcare?

To improve organizational and client safety Signup and view all the answers

What is the main purpose of identifying circumstances that lead to errors?

To improve performance and reduce errors Signup and view all the answers

What is the main benefit of having contingencies in place to cope with problems?

To reduce the impact of interruptions and distractions Signup and view all the answers

Study Notes

Patient Safety

Patient safety is the absence or reduction of risk of unnecessary harm to a patient during healthcare to an acceptable minimum.
There are more deaths annually due to healthcare than from road accidents, breast cancer, and AIDS combined.

The 6 Key Dimensions 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.

Sources of System Errors

Active (human) errors: Committed by frontline staff and tend to have direct patient consequences.
Latent or system errors: Errors that occur due to a set of external forces and indirect failures involving management, protocols/processes, organizational culture, transfer of knowledge, and external factors.

Serious Injury and Adverse Events

Serious injury includes loss of limb or function.
Adverse drug reaction: A response to a drug that is noxious and unintended, which occurs at a dose normally used in man for the prophylaxis, diagnosis, or therapy of disease, or for the modification of physiological function.
Near miss: Any situation that might have resulted in harm, but did not reach the patient due to timely intervention or good fortune.

Maintaining Safety in Clinical Incidents

Adhere to and follow national patient safety goals and required organizational practices (ROP).

Human Factors and Patient Safety

Human factors: The study of all the factors that make it easier to do the work in the right way; also known as ergonomics.
Importance of human factors in healthcare: Human factors are a major contributor to adverse events in healthcare, and all healthcare workers need to have a basic understanding of human factors principles.

Human Factors Principles

Acknowledge: The universal nature of human fallibility and the inevitability of error.
Assume: That all errors will occur.
Design: Designs things in the workplace to try to minimize the likelihood of error or its consequences.

Examples of Traps in Healthcare

Look-alike and sound-alike medications.
Equipment design complexity, e.g., infusion pump.

Systems Approach

A systems approach requires looking at healthcare as a whole system, with all its complexity and interdependence, shifting the focus from the individual to the organization.
It forces us to move away from a blame culture towards a systems approach.

Traditional Approach to Problems

Blame and shame the healthcare professionals most directly involved in caring for the patient at the time of an adverse event or error.
Why it's not accepted: Healthcare professionals do not deliberately harm patients, and a blame culture makes it difficult to learn from errors and decrease the chance of future adverse incidents.

Accountability

Accountability is a professional obligation for healthcare professionals.
Importance of accountability: To demonstrate professional behavior, ensure working within scope of practice, and maintain competence and practice ethically.

Stages of Team Development

Forming stage: Initial stage when the team is formed, and members are coming together for the first time.
Storming stage: Each member tends to rely on their own experience, and there is resistance to work together openly.
Norming stage: Members start to know each other, accept each other's ideas and opinions, and work together to overcome personal disagreements.
Performing stage: Members are satisfied with the team's progress, and work together to achieve the team's goals.

Characteristics of Successful Teams

Measurable goals: Teams set goals that are measurable and focused on the team's task.
Mutual respect: Effective teams have members who respect each other's talents and beliefs.
Common purpose: Identification of potential improvements that could be made in systems or processes to improve performance and reduce the likelihood of adverse events or close calls.

Practice Strategies to Reduce Errors

Know yourself: Eat well, sleep well, and look after yourself.
Know your environment and know your task(s).
Preparation and planning: What if...?
Build checks into the routine and ask if you do not know.
Assume that errors will be made, be prepared for them, and identify those circumstances that most likely lead to errors.
Have contingencies in place to cope with problems, interruptions, and distractions.
Always mentally rehearse complex procedures or if it is the first time you are doing an activity involving a patient.

Understanding and Managing Clinical Risk

Risk management: Organizational effort to identify, assess, control, and evaluate the risk to reduce harm to patients, visitors, and staff and protect the organization from financial loss.
Purpose of risk management: Improve organizational and client safety, identify and minimize risks and liability losses, protect the organization's resources, support regulatory and accreditation compliance, and create safe systems of care designed to reduce adverse events and improve human performance.
Hazard: Any activity, situation, or substance that has the potential to cause harm, including ill health, injury, loss of product, and/or damage to patients and property.
Risk: The probability that harm will actually occur.

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Description

Learn about patient safety, its importance, and the 6 key dimensions of healthcare quality, including safety and effectiveness.