Patient Safety 3

A structured method to analyze risks associated with specific processes, events, or equipment used in healthcare settings. It actively identifies potential threats and prepares for future adverse events.

A tool for analyzing the chain of events that could lead to a negative outcome. Used in PRA to understand the potential consequences of a failure.

A method for evaluating the likelihood and severity of potential failures in a process or system. Used in PRA to identify critical points needing improvement.

A thorough examination of a process or procedure, focusing on identifying potential threats and risks. Helpful for identifying areas needing improvement.

Identifying the specific areas or processes that will be the focus of the PRA. Limiting the study to a manageable scope.

Identifying and analyzing the 'real work' done, contrasting it with the 'ideal work' as described in guidelines or policies.

Developing and using methods like checklists, interviews, or simulations to collect data and gain insights from professionals directly involved in the assessed process.

Evaluating the impact of possible failures on patients, staff, or the healthcare system. Assessing the severity of each potential problem.

A tool used after an incident or error occurs to figure out the root cause of the problem. It looks at all the factors that might have contributed, including people, the environment, equipment, policies, and leadership.

Similar to a detective's 'Why?' questions, RCA aims to uncover the underlying reasons for an event by repeatedly asking 'Why?' This helps identify the main issues and not just the symptoms.

Red Rules are safety guidelines used in high-risk industries like aviation and manufacturing. They are also becoming popular in healthcare because they empower anyone to stop a procedure or process if they see a safety violation.

Red Rules are designed to be easily understood and followed by everyone, regardless of their position or seniority. They help create a culture where safety is everyone's responsibility.

Red Rules encourage a culture of speaking up. If someone sees a violation, they have the authority and responsibility to stop the process to protect patients and staff.

Managers play a crucial role in supporting the use of Red Rules. They need to create a work environment where staff feel safe and empowered to raise safety concerns without fear of punishment.

A structured process used to identify the root cause of an event or error, understand the underlying factors, and develop corrective actions to prevent similar incidents in the future.

It involves a systematic approach to reviewing the event, investigating the contributing factors, and identifying the underlying reasons behind the occurrence.

A team dedicated to conducting the entire RCA² process, ensuring consistency and continuity in the review.

It includes the initial response to the event, securing the situation, and collecting evidence. This is followed by prioritizing the issue based on its potential impact.

It involves gathering information and documenting the sequence of events that occurred, helping to understand the flow and timeline of the event.

It focuses on identifying the root causes by analyzing the relationships between different factors, uncovering the underlying reasons behind the event.

Once the root causes are identified, solutions and corrective actions are proposed to address those causes and prevent similar incidents from happening again.

Implementation of the proposed solutions and corrective actions is crucial. This involves putting the plan into practice and making the necessary changes to prevent future errors.

Safety guidelines used in healthcare, similar to those used in aviation and manufacturing, that empower anyone to stop a procedure or process if they see a safety violation.

Red Rules aim to be easily understood and followed by all healthcare staff, regardless of their position or seniority. They encourage a 'safety first' culture.

Checklists help avoid forgetting crucial steps in complex healthcare procedures. They are based on evidence and improve patient safety by reducing human errors.

Checklists are designed to be algorithmic, meaning they involve a specific sequence of actions. This ensures consistency and reliability in healthcare procedures.

Checklists can be used to prepare, implement, monitor, and evaluate workforce and environmental safety in healthcare settings. They help identify potential hazards and risks.

Examples of hazards in healthcare settings include blood-borne pathogens, potential drug exposures, respiratory hazards, ergonomic risks, and workplace violence.

Checklists promote a culture of safety by ensuring adherence to infection control practices. This can significantly reduce infections, improving patient outcomes.

Checklists can be customized for internal processes or for external use by patients. Examples include surgical checklists, checklists for safe childbirth, and checklists for trauma care.

Using Red Rules as a disciplinary tool can be perceived as blaming and punitive, which contradicts the principles of a just culture. They should be used to support staff, not punish them.

A just culture emphasizes transparency and trust. Red Rules can be effective when implemented within a commitment-based management style that encourages staff to follow safety rules without fear of punishment.

These precautions treat all bodily fluids as potentially infectious, regardless of the patient's known status. This prevents accidental exposure to bloodborne pathogens.

These needles are designed to minimize the risk of accidental needle sticks during medical procedures. This helps protect healthcare workers from bloodborne pathogens.

Washing exposed skin immediately after contact with potentially infectious materials helps reduce the chance of contracting bloodborne pathogens.

Designated areas for eating, drinking, and personal care minimize the risk of transferring potentially infectious materials from work areas to these activities.

Providing Hepatitis B vaccinations to employees who are exposed to blood or OPIM helps prevent them from becoming infected with the virus.

Maintaining a sufficient supply of personal protective equipment (PPE) ensures employees are protected from exposure to bloodborne pathogens.

Eye wash stations must be readily accessible in case of accidental exposure to blood or OPIM. They help prevent serious eye damage.

Sharps containers must be readily available and regularly inspected to ensure they are not overfilled and pose a risk of injury to employees.

A regular schedule for cleaning and disinfecting equipment and work surfaces that may come in contact with blood or OPIM helps prevent the spread of infectious materials.

Creating and following facility policies helps ensure that employees understand their responsibilities in preventing exposure to bloodborne pathogens.

A program designed to identify and reduce the risk of infections among patients, staff, and visitors. It focuses on surveillance, prevention, and control measures.

Infections acquired during a patient's stay in a healthcare setting, often due to factors like weak immune systems, invasive procedures, or inadequate hygiene.

The process of actively identifying potential risks and vulnerabilities in an organization's operations, including patient care, staff safety, and environmental factors.

Measures taken to prevent the spread of infection, including hand hygiene, use of personal protective equipment, and appropriate disinfection practices.

A key strategy for infection control, involving regular cleaning and disinfection of surfaces, equipment, and the environment to prevent the transmission of germs.

The study of patterns and causes of infection and disease within populations, helping to identify trends, outbreaks, and potential interventions.

The practice of educating healthcare workers about proper infection prevention practices, such as hand hygiene, isolation procedures, and appropriate use of personal protective equipment.

Protocols and procedures designed to minimize the risk of infection transmission, including isolation guidelines for patients with infectious conditions, hand hygiene procedures, and use of personal protective equipment.

The practice of recording and analyzing data related to infections, including types of infections, patient demographics, and factors contributing to infections, to identify trends and improve prevention strategies.

A type of technology designed to keep patients safe within a healthcare setting, including alarms for wandering, falls, and alerts on mobile devices.

Electronic systems used to identify patterns and learn from errors in healthcare, including medical records, staffing data, and automated reports.

The idea of seamlessly connecting different healthcare systems and technologies for improved patient care and efficiency.

Leadership's role in implementing health IT and ensuring its safe and responsible use.

Essential elements of Electronic Health Records (EHRs), including clinical documentation, results management, e-prescribing, and clinical decision support.

The focus on safety and reliability of health IT systems, recognizing the importance of technology, people, processes, and organizational culture for successful implementation.

Potential issues with EHRs, including workarounds and alarm fatigue, and incorrect patient matching.

A structured method for identifying the root cause of an adverse event or error in healthcare, by systematically reviewing the event, investigating contributing factors, and identifying underlying reasons.

Safety guidelines used in healthcare that empower staff to stop a procedure or process if they see a safety violation.

Checklists used in healthcare to avoid forgetting crucial steps in complex procedures, improving safety by minimizing human errors.

This framework encompasses eight dimensions, both technological and non-technological, to assess HIT safety. It incorporates external factors like payment systems, legal aspects, national quality initiatives, accreditation, and regulatory requirements.

These errors can occur due to flawed matching algorithms, data quality issues like incomplete data or duplicate records, and loss of data integrity during transmission.

AI describes computer applications that mimic human intellect, like reasoning, generalizing, and learning. It's used to analyze vast amounts of data and find patterns for predictive modeling, predicting future outcomes based on past information.

Developed to improve the use of health IT, the NHIN provides standards, services, and a trust fabric for secure exchange of health information over the internet. It aims to make health information accessible for clinical decision-making and beyond direct patient care.

This platform facilitates the sharing of health information between various entities, supporting the goals of the Health Information Technology for Economic and Clinical Health Act.

This type of software is vital for community-wide patient safety, enabling local and national efforts in improving health IT. It promotes collaboration and sharing of resources.

These domains focus on the safe use of health IT, ensuring its integrity, availability, and confidentiality. They also consider usability, complete use, and correct use of the technology by healthcare professionals.

The framework emphasizes the importance of integration with existing clinical risk management programs, organizational learning, shared responsibility, 360° assessments, and refining measurement tools and strategies.

They are designed to be important, scientifically acceptable, transparent, feasible, and usable. By incorporating these principles, they ensure the effectiveness and reliability of the measurements.

Safer HIT-enabled healthcare leads to improved value in healthcare delivery, improved patient outcomes, and provides valuable feedback to EHR developers and healthcare organizations. It also promotes a culture of continuous learning and improvement.

An electronic system that allows providers to record, store, retrieve, and modify orders (e.g., prescriptions, diagnostic tests, treatment).

Provides evidence-based clinical suggestions to health professionals at the point of care.

Used to track medications, orders, and other healthcare products. It can also verify patient identification and dosage.

Tools like patient portals, smartphone apps, and emails that allow patients to participate in their healthcare.

Increases in legible orders, shorter order turnaround times, and lower risk of medication errors.

Increased ordering time, new opportunities for errors, and potential disruptions in workflow.

Reductions in medication errors, toxic drug levels, and time to therapeutic stabilization.

Rates of detecting drug-drug interactions vary widely among different vendors, and there can be an increase in mortality rate.

Significant reductions in medication errors associated with transcription, dispensing, and administration.

Introduction of workarounds, such as clinicians scanning medications without visually checking for accuracy.

This type of AI analyzes huge amounts of healthcare data to find patterns and predict what might happen in the future.

A crucial aspect of ensuring safe and effective use of health information technology (HIT), it involves checking the integrity, availability, and confidentiality of technology.

Also known as the '5 Whys,' this method helps uncover the root cause of an incident in healthcare by repeatedly asking 'Why?' until the underlying issue is identified.

It involves connecting different healthcare systems and technologies to improve patient care.

This type of healthcare error occurs when healthcare professionals use workarounds or bypass safety features in health IT systems, leading to potential risks.

This type of healthcare error occurs when healthcare providers receive too many alarms from medical devices or health IT systems, potentially leading to desensitization and missed warnings.

It's a multi-stakeholder group working to optimize health IT for safer care.

They are designed to minimize the risk of accidental needle sticks during medical procedures.

Using consistent and standardized patient identification information across all electronic systems to avoid duplicate records and ensure accurate matching.

Verifying patient identity through multiple checks, such as name, birthdate, and medical record number.

Using standard formats and attributes for patient information across systems to enhance match accuracy and avoid incorrect linking.

Presenting patient information consistently across different health IT systems to make identification easier and more accurate.

Highlighting key patient information on screens and printouts using visual cues like font, color, or white space to make identification more visible.

Exploring and integrating new technologies to improve patient identification processes, such as facial recognition or biometrics.

Monitoring systems to detect errors in patient identification, helping to prevent duplication and wrong record matching.

Using notifications to alert users when there are potential identification issues, like duplicate records or wrong patient selection.

A national safety surveillance program that collects information about adverse events following the administration of vaccines in the U.S., including COVID-19 vaccines.

A database that tracks adverse events and product complaints reported to the FDA related to foods, dietary supplements, and cosmetics.

A system used to track patient safety data related to infection prevention and control, especially regarding healthcare-associated infections (HAIs).

A system that assigns ratings to hospitals and outpatient facilities based on their performance in various areas, including patient safety.

A system that encourages healthcare facilities to voluntarily or mandatorily report adverse events to improve patient safety, but mandates vary by state.

A type of technology designed to protect patients in a healthcare setting by using alarms for potentially dangerous situations like wandering, falls, or emergencies.

A common issue faced in healthcare technology, where users bypass safety features in electronic systems, potentially leading to errors.

A system for exchanging health information between different healthcare entities, aiming to improve patient care and efficiency.

A framework that assesses eight key aspects of health information technology (HIT) to promote safer and more effective use of these systems.

A long-standing organization that worked with CMS to improve hospital quality measures, including the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), but ended in 2012.

A set of standards and measures used by the National Committee for Quality Assurance (NCQA) to hold health plans accountable for the care they provide. It is widely used in the US.

Safety guidelines designed to empower all healthcare staff to stop unsafe procedures or processes. They create a culture where safety is everyone's responsibility.

Checklists used in healthcare to prevent mistakes in complex procedures. They improve patient safety by reducing human errors.

A collection of standards and activities used by the Joint Commission to assist healthcare organizations in achieving patient safety through accreditation and data analysis.

The practice of using electronic systems to collect, store, analyze, and share patient health information, enhancing efficiency and improving patient care.

This framework aims to promote the safe use of health information technology (HIT) by examining its integrity, availability, and confidentiality.

This group aims to improve patient safety, quality of healthcare, and affordability by encouraging hospitals to embrace best practices.

The Joint Commission sets standards for hospitals and other healthcare organizations. These goals are meant to increase patient safety by addressing specific areas of risk.

This involves ensuring that the correct patient is identified before any procedure or treatment is given. This helps avoid mistakes and ensure that patients receive the right care.

This means that all healthcare professionals involved in a patient's care must communicate effectively to ensure continuity and accurate information sharing.

Important for ensuring that medications are used safely and correctly. This includes verifying medications and addressing any inconsistencies.

Focuses on preventing infections that can occur in healthcare settings. This includes following hand hygiene guidelines and implementing infection control practices.

This means hospitals should identify patients at risk for suicide and offer appropriate support and intervention. It emphasizes a zero suicide approach.

This protocol aims to prevent wrong-site, wrong-procedure, and wrong-person surgeries. A 'time-out' is a crucial part, involving a checklist and team confirmation before the procedure.

Using technology to improve patient safety and quality of care. This includes electronic health records (EHRs), patient portals, and clinical decision support systems.

A standardized communication tool used by healthcare providers to describe a patient's condition and facilitate care. It involves a structured approach to information sharing, emphasizing communication clarity and conciseness.

A voluntary consensus standards-setting organization recognized as a leader in patient safety. It sets standards for healthcare measurement, recommends measures for use in payment and public reporting programs, advances electronic measurement, and provides information and tools to help healthcare decision-makers.

Checklists used in healthcare to avoid forgetting crucial steps in complex procedures, improving safety by minimizing human errors.