Questions and Answers
Which of the following is a latent unsafe condition in the system that contributes to the resident's error?
What would be the best course of action to prevent messy handwriting from causing miscommunication?
Develop a system that prevents messy handwriting from causing miscommunication that leads to error.
What are 'latent errors' best defined as?
Defects in the design and organization of processes and systems.
What is the active error in the scenario with Ms. Tyler and Ms. Taylor?
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What is one of the latent errors in the scenario with Ms. Tyler and Ms. Taylor?
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By definition, what does an 'unsafe act' always include?
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What type of error is represented by Anita's failure to tell Mr. Drummond to increase his insulin dose?
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What type of unsafe act does Mike's decision to substitute medications represent?
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What is the most significant advantage of shifting to a systems view of safety within health care?
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What type of error is the hand washing intervention at University Hospital best designed to address?
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What intervention proved that catheter-associated bloodstream infections (CLABSIs) were preventable?
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What is one reason that patient safety has shifted to work on reducing harm?
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What is included in the IHI Global Trigger Tool definition of harm?
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What important concept in patient safety does the Swiss cheese model of harm illustrate?
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Why do some patient safety leaders believe the definition of harm should be broader?
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Study Notes
Errors in Patient Safety
- Long work schedules contribute to latent unsafe conditions, increasing the risk of errors, as seen in the prescription of incorrect insulin dosage.
- Developing a system to prevent miscommunication due to messy handwriting can help mitigate future errors.
Types of Errors
- Latent errors refer to defects in the design and organization of processes and systems that predispose individuals to mistakes.
- Active errors manifest in direct actions, such as the incorrect administration of medications to patients.
- Lapses occur when professionals forget critical actions, demonstrated when a nurse fails to inform a patient about increasing their insulin dose.
Unsafe Acts
- Unsafe acts include both violations (consciously ignoring protocols for expedience) and potential hazards that can lead to harm.
- A violation is evident when a pharmacy technician substitutes medications without consulting the prescriber.
System Safety Approach
- Shifting to a systems perspective in healthcare enhances safety by changing working conditions and addressing latent errors.
- Hand hygiene campaigns address lapses attributed to poor staff adherence to existing protocols.
Prevention of Harm
- Evidence-based checklists significantly reduce preventable infections, highlighting the importance of consistent practice in patient care.
- Recognition that harm is more preventable than previously assumed reflects an evolution in patient safety culture.
IHI Global Trigger Tool
- The definition of harm includes physical injuries resulting from medical care that necessitate additional treatment.
- The Swiss cheese model emphasizes that both latent unsafe conditions and active errors contribute to patient harm, reinforcing the significance of layered defenses in healthcare systems.
Broader Definitions of Harm
- Patient safety experts advocate for a broader definition of harm, urging healthcare systems to target a wider array of preventable adverse outcomes beyond those specified in traditional definitions.
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Description
This quiz focuses on the critical concepts of patient safety, particularly in the context of medical errors and their implications. Explore cases that highlight how systemic issues can lead to significant harm, emphasizing the importance of vigilance and system improvements in healthcare settings.
