Podcast
Questions and Answers
What must a healthcare worker (HCW) do immediately after identifying a safety event?
What must a healthcare worker (HCW) do immediately after identifying a safety event?
- Develop a clinical care plan
- Notify their line manager (correct)
- Document the event in the patient file
- Notify the patient and their family
A safety event report can include the names of the patient and the staff involved.
A safety event report can include the names of the patient and the staff involved.
False (B)
What is required before engaging with the patient or their family after a safety event?
What is required before engaging with the patient or their family after a safety event?
Legal advice
The HCW must complete the event report on the Safety Event Management System before the end of the __________.
The HCW must complete the event report on the Safety Event Management System before the end of the __________.
Match the following steps in the management of a safety event:
Match the following steps in the management of a safety event:
Which type of information is NOT required on the Safety Event Report?
Which type of information is NOT required on the Safety Event Report?
The patient's treating doctor does not need to be notified if no harm occurred from the safety event.
The patient's treating doctor does not need to be notified if no harm occurred from the safety event.
Name one role of the PxM in the management of a safety event.
Name one role of the PxM in the management of a safety event.
What must happen within 5 working days of an event being reported?
What must happen within 5 working days of an event being reported?
The ISBAR layout is used for reporting all safety events without exception.
The ISBAR layout is used for reporting all safety events without exception.
What should be done if agency staff members are involved in a safety event?
What should be done if agency staff members are involved in a safety event?
The level of __________ as selected by the reporter must be reviewed and changed to the most appropriate harm level.
The level of __________ as selected by the reporter must be reviewed and changed to the most appropriate harm level.
Match the following terms with their definitions:
Match the following terms with their definitions:
Which of the following is a requirement if the event results in serious harm or death?
Which of the following is a requirement if the event results in serious harm or death?
Classification of multiple events requires identifying common causal factors.
Classification of multiple events requires identifying common causal factors.
What is the purpose of reviewing the Type of Event selected by the reporter?
What is the purpose of reviewing the Type of Event selected by the reporter?
What must all reports include, even if submitted anonymously?
What must all reports include, even if submitted anonymously?
The After Action Review focuses on discussing the future actions to prevent harm.
The After Action Review focuses on discussing the future actions to prevent harm.
What are the two types of events that must document all questions in the After Action Review?
What are the two types of events that must document all questions in the After Action Review?
The Unit/Line Manager must conduct an Initial Review to ensure _____ and correctness.
The Unit/Line Manager must conduct an Initial Review to ensure _____ and correctness.
Match the step with its description:
Match the step with its description:
What should the Unit/Line Manager do after reporting an event verbally?
What should the Unit/Line Manager do after reporting an event verbally?
The First Team Review can occur after the After Action Review.
The First Team Review can occur after the After Action Review.
Which framework is used to identify contributing factors during investigations?
Which framework is used to identify contributing factors during investigations?
During the First Team Review, the Unit/Line Manager ensures that _____ principles are adhered to.
During the First Team Review, the Unit/Line Manager ensures that _____ principles are adhered to.
What must be documented in the Safety Event Management System for a low harm event?
What must be documented in the Safety Event Management System for a low harm event?
Investigations are required only for serious harm or death events.
Investigations are required only for serious harm or death events.
What is the primary purpose of conducting an After Action Review?
What is the primary purpose of conducting an After Action Review?
An event that poses a risk of patient harm must be discussed with the _____ Department.
An event that poses a risk of patient harm must be discussed with the _____ Department.
Match the following actions with their corresponding terms:
Match the following actions with their corresponding terms:
What is primarily expected from the outcomes of analysis following a safety event?
What is primarily expected from the outcomes of analysis following a safety event?
Which of the following best describes an 'almost harmed' situation in patient safety management?
Which of the following best describes an 'almost harmed' situation in patient safety management?
What role does the Legal Department play in the management of safety events?
What role does the Legal Department play in the management of safety events?
Which of the following actions is required following safety events that result in serious harm or death?
Which of the following actions is required following safety events that result in serious harm or death?
What best describes a Never Event?
What best describes a Never Event?
What should be documented in the Safety Event Management System for low harm events?
What should be documented in the Safety Event Management System for low harm events?
Which of the following is NOT a part of the DMAIC process?
Which of the following is NOT a part of the DMAIC process?
What is the role of the Serious Event Management Team (SEMT)?
What is the role of the Serious Event Management Team (SEMT)?
In which scenario is an Adverse Event defined as having occurred?
In which scenario is an Adverse Event defined as having occurred?
Which best describes the concept of Psychological Safety in a team?
Which best describes the concept of Psychological Safety in a team?
What is the correct order of steps in the management of safety events?
What is the correct order of steps in the management of safety events?
Which category of safety event includes those that must be reported to a regulatory authority?
Which category of safety event includes those that must be reported to a regulatory authority?
What characterizes a Near Miss event?
What characterizes a Near Miss event?
Which level of harm indicates that a patient can expect full recovery within a short duration?
Which level of harm indicates that a patient can expect full recovery within a short duration?
What is the primary focus during an After Action Review (AAR)?
What is the primary focus during an After Action Review (AAR)?
What is the minimum requirement for reporting a safety event anonymously?
What is the minimum requirement for reporting a safety event anonymously?
Which question is NOT typically included in the After Action Review (AAR)?
Which question is NOT typically included in the After Action Review (AAR)?
During the First Team Review, what must be evaluated for appropriateness?
During the First Team Review, what must be evaluated for appropriateness?
What must happen if an event resulted in severe harm or death?
What must happen if an event resulted in severe harm or death?
Which aspect should be documented for No, Low, and Moderate harm events in the Safety Event Management System?
Which aspect should be documented for No, Low, and Moderate harm events in the Safety Event Management System?
What must the PSM do within 5 working days after an event is reported?
What must the PSM do within 5 working days after an event is reported?
Which of the following is NOT a responsibility of the Serious Event Management Team (SEMT)?
Which of the following is NOT a responsibility of the Serious Event Management Team (SEMT)?
What is the purpose of conducting a preliminary investigation by the PSM?
What is the purpose of conducting a preliminary investigation by the PSM?
How should the event be classified if it is serious harm or results in death?
How should the event be classified if it is serious harm or results in death?
What should the Unit Manager ensure regarding the actions determined from the event analysis?
What should the Unit Manager ensure regarding the actions determined from the event analysis?
What must occur following the completion of an event investigation in relation to the Final Review?
What must occur following the completion of an event investigation in relation to the Final Review?
Which report is considered the preferred format for documenting serious harm events?
Which report is considered the preferred format for documenting serious harm events?
What is the responsibility of the Unit Manager concerning actions planned in response to a safety event?
What is the responsibility of the Unit Manager concerning actions planned in response to a safety event?
When should all safety events be loaded and managed to ensure reflection in Clinical Indicator Reports?
When should all safety events be loaded and managed to ensure reflection in Clinical Indicator Reports?
What action should be taken if the event involves agency staff members?
What action should be taken if the event involves agency staff members?
What key factor must be included in reports for serious events requiring system analysis?
What key factor must be included in reports for serious events requiring system analysis?
Who is responsible for ensuring that the alert distribution email groups are maintained?
Who is responsible for ensuring that the alert distribution email groups are maintained?
What is the timeline for reporting contributing factors after a safety event is reported?
What is the timeline for reporting contributing factors after a safety event is reported?
What is the primary purpose of utilizing the SMART principles in addressing Safety Events?
What is the primary purpose of utilizing the SMART principles in addressing Safety Events?
Which role is primarily responsible for driving improvement initiatives in a unit?
Which role is primarily responsible for driving improvement initiatives in a unit?
What is the correct sequence in the DMAIC continuous improvement methodology?
What is the correct sequence in the DMAIC continuous improvement methodology?
After a Never Event is reported, within how many hours must the event report be emailed to the Regional Clinical Manager?
After a Never Event is reported, within how many hours must the event report be emailed to the Regional Clinical Manager?
Which maternal death category refers to deaths caused directly by a pregnancy complication?
Which maternal death category refers to deaths caused directly by a pregnancy complication?
What type of neonatal event does NOT require reporting due to known complications?
What type of neonatal event does NOT require reporting due to known complications?
Who is responsible for managing healthcare-associated infections within a unit?
Who is responsible for managing healthcare-associated infections within a unit?
What is the primary impact of immigration on a country's population?
What is the primary impact of immigration on a country's population?
What historical period is associated with the beginning of significant population growth due to advancements in agriculture?
What historical period is associated with the beginning of significant population growth due to advancements in agriculture?
Which factor is considered in calculating the birth rate of a country?
Which factor is considered in calculating the birth rate of a country?
Which country has a noteworthy high birth and death rate mentioned?
Which country has a noteworthy high birth and death rate mentioned?
What could potentially lead to a high death rate in a population?
What could potentially lead to a high death rate in a population?
What is a consequence of rapid population growth mentioned in the content?
What is a consequence of rapid population growth mentioned in the content?
Which of the following best describes emigration?
Which of the following best describes emigration?
Which of the following statements is accurate regarding death rates globally?
Which of the following statements is accurate regarding death rates globally?
What primarily influences rapid population growth in a country?
What primarily influences rapid population growth in a country?
How is the population growth rate calculated?
How is the population growth rate calculated?
What does a high infant mortality rate indicate about a country's health system?
What does a high infant mortality rate indicate about a country's health system?
Which factor is likely to lead to lower population growth rates in a country?
Which factor is likely to lead to lower population growth rates in a country?
What was the global average life expectancy according to WHO in 2022?
What was the global average life expectancy according to WHO in 2022?
Which factor tends to decrease mortality and fertility rates in a country?
Which factor tends to decrease mortality and fertility rates in a country?
Which region had the highest recorded life expectancy as per the provided data?
Which region had the highest recorded life expectancy as per the provided data?
What would typically cause a region's population to grow?
What would typically cause a region's population to grow?
In what way can age distribution affect population dynamics?
In what way can age distribution affect population dynamics?
What effect does economic development usually have on population growth rates?
What effect does economic development usually have on population growth rates?
What is the primary focus of environmental conservation?
What is the primary focus of environmental conservation?
Which of the following represents an ecological reason for conservation?
Which of the following represents an ecological reason for conservation?
What term is used for areas set aside to protect natural ecosystems and wildlife?
What term is used for areas set aside to protect natural ecosystems and wildlife?
Which economic reason is crucial for conservation efforts?
Which economic reason is crucial for conservation efforts?
What ethical belief underlies the importance of nature conservation?
What ethical belief underlies the importance of nature conservation?
What is a significant threat to conservation efforts in South Africa?
What is a significant threat to conservation efforts in South Africa?
Which option best describes an aesthetic reason for conservation?
Which option best describes an aesthetic reason for conservation?
Which of the following definitions aligns with conservation areas in oceans?
Which of the following definitions aligns with conservation areas in oceans?
What is a primary threat to the habitats of animals within urban areas?
What is a primary threat to the habitats of animals within urban areas?
Which of the following represents a benefit of wetlands?
Which of the following represents a benefit of wetlands?
What type of area is specifically designated for scientific research and observation of ecological changes?
What type of area is specifically designated for scientific research and observation of ecological changes?
What is an important purpose of Transfrontier Conservation Areas (TFCAs) in South Africa?
What is an important purpose of Transfrontier Conservation Areas (TFCAs) in South Africa?
Which of the following is NOT a type of conservation area recognized in South Africa?
Which of the following is NOT a type of conservation area recognized in South Africa?
How can individuals contribute to conservation efforts in South Africa?
How can individuals contribute to conservation efforts in South Africa?
What is a significant consequence of climate change on ecosystems?
What is a significant consequence of climate change on ecosystems?
Which of the following describes a characteristic feature of grasslands?
Which of the following describes a characteristic feature of grasslands?
What unique aspect do biosphere reserves encompass?
What unique aspect do biosphere reserves encompass?
Which of the following contributes to pollution as a threat to wildlife?
Which of the following contributes to pollution as a threat to wildlife?
Which is a primary role of the South African National Parks (SANParks)?
Which is a primary role of the South African National Parks (SANParks)?
What is the significance of marine protected areas (MPAs) in South Africa?
What is the significance of marine protected areas (MPAs) in South Africa?
What percentage of South Africa is covered by forests?
What percentage of South Africa is covered by forests?
Which type of conservation area involves significant restrictions on access and development?
Which type of conservation area involves significant restrictions on access and development?
Which marketing strategy is emphasized as critical for attracting new patients in healthcare services?
Which marketing strategy is emphasized as critical for attracting new patients in healthcare services?
What is a significant benefit of employing marketing techniques in healthcare services?
What is a significant benefit of employing marketing techniques in healthcare services?
What is one of the main objectives of the marketing strategies used in tertiary care hospitals?
What is one of the main objectives of the marketing strategies used in tertiary care hospitals?
Which of the following factors is least likely to be influenced by pharmaceutical marketing mix strategies?
Which of the following factors is least likely to be influenced by pharmaceutical marketing mix strategies?
Which method is suggested to encourage current patients to refer others to the hospital?
Which method is suggested to encourage current patients to refer others to the hospital?
What aspect of patient engagement is deemed essential for creating a memorable experience?
What aspect of patient engagement is deemed essential for creating a memorable experience?
How does internal marketing impact job satisfaction within health services?
How does internal marketing impact job satisfaction within health services?
Which of the following is NOT identified as a major marketing tactic for healthcare services?
Which of the following is NOT identified as a major marketing tactic for healthcare services?
In the context of tertiary care hospitals, what is the primary objective of the marketing mix strategy?
In the context of tertiary care hospitals, what is the primary objective of the marketing mix strategy?
What is the primary purpose of healthcare marketing strategies?
What is the primary purpose of healthcare marketing strategies?
Which aspect of hospital management relates directly to the influence of marketing mix on healthcare services?
Which aspect of hospital management relates directly to the influence of marketing mix on healthcare services?
What is one of the primary components of digital marketing in healthcare services?
What is one of the primary components of digital marketing in healthcare services?
What marketing practice directly communicates with customers to provide quantifiable responses?
What marketing practice directly communicates with customers to provide quantifiable responses?
Which of the following is NOT part of the marketing communication mix used in healthcare?
Which of the following is NOT part of the marketing communication mix used in healthcare?
What was the impact on healthcare organizations when advertising restrictions were lifted?
What was the impact on healthcare organizations when advertising restrictions were lifted?
Which aspect is essential for hospitals to enhance patient involvement according to marketing tactics?
Which aspect is essential for hospitals to enhance patient involvement according to marketing tactics?
How do hospitals primarily assess the effectiveness of their marketing strategies?
How do hospitals primarily assess the effectiveness of their marketing strategies?
What is a key element that is investigated in the study regarding marketing methods in tertiary care hospitals?
What is a key element that is investigated in the study regarding marketing methods in tertiary care hospitals?
Which factor influences the visibility of hospitals among potential patients?
Which factor influences the visibility of hospitals among potential patients?
What is the expected outcome of implementing effective marketing strategies in healthcare organizations?
What is the expected outcome of implementing effective marketing strategies in healthcare organizations?
What benefit does direct marketing provide that traditional methods may not offer?
What benefit does direct marketing provide that traditional methods may not offer?
What is an essential component of direct marketing strategies in healthcare?
What is an essential component of direct marketing strategies in healthcare?
Which of the following best describes the role of the public relations department in a hospital?
Which of the following best describes the role of the public relations department in a hospital?
What is a primary goal of the education provided to front-line staff members?
What is a primary goal of the education provided to front-line staff members?
Which method is NOT associated with direct marketing in healthcare?
Which method is NOT associated with direct marketing in healthcare?
How should hospital floor managers ensure compliance with patient communication standards?
How should hospital floor managers ensure compliance with patient communication standards?
What is one of the duties of public relations officers in a hospital?
What is one of the duties of public relations officers in a hospital?
Which aspect is crucial for maintaining effective patient relations in healthcare marketing?
Which aspect is crucial for maintaining effective patient relations in healthcare marketing?
What strategy should be part of a hospital's public relations plan?
What strategy should be part of a hospital's public relations plan?
Which of the following describes a common misconception about direct marketing in health services?
Which of the following describes a common misconception about direct marketing in health services?
What should be prioritized when implementing direct communication methods with patients?
What should be prioritized when implementing direct communication methods with patients?
What is a key element that distinguishes social marketing from traditional advertising tactics?
What is a key element that distinguishes social marketing from traditional advertising tactics?
Which of the following elements is not part of the healthcare marketing mix commonly recognized by the 7Ps model?
Which of the following elements is not part of the healthcare marketing mix commonly recognized by the 7Ps model?
What is one limitation identified in the context of marketing in healthcare?
What is one limitation identified in the context of marketing in healthcare?
Which marketing strategy is emphasized in public hospitals to enhance staff and patient relationships?
Which marketing strategy is emphasized in public hospitals to enhance staff and patient relationships?
What should be the primary aim of marketing in the healthcare sector?
What should be the primary aim of marketing in the healthcare sector?
In the context of healthcare services, what aspect does the pharmaceutical advertising mix specifically focus on?
In the context of healthcare services, what aspect does the pharmaceutical advertising mix specifically focus on?
How does marketing communication particularly benefit management in public hospitals?
How does marketing communication particularly benefit management in public hospitals?
Which of the following best describes the role of social marketing in healthcare?
Which of the following best describes the role of social marketing in healthcare?
How can the application of lean methodology benefit nonprofit hospitals?
How can the application of lean methodology benefit nonprofit hospitals?
What aspect of healthcare marketing is critical for informing patients about services?
What aspect of healthcare marketing is critical for informing patients about services?
What is the primary purpose of conducting ward rounds according to the policy?
What is the primary purpose of conducting ward rounds according to the policy?
Which document is maintained by the Patient Experience Manager?
Which document is maintained by the Patient Experience Manager?
What is an important aspect of feedback after conducting patient rounds?
What is an important aspect of feedback after conducting patient rounds?
Which action should follow after addressing patient needs during ward rounds?
Which action should follow after addressing patient needs during ward rounds?
What is one of the main responsibilities of Patient Experience Managers during ward rounds?
What is one of the main responsibilities of Patient Experience Managers during ward rounds?
What should discussions about service failures include during management meetings?
What should discussions about service failures include during management meetings?
What is the primary aim of conducting ward rounds as outlined in the policy?
What is the primary aim of conducting ward rounds as outlined in the policy?
Which version of the policy went into effect on 19 May 2023?
Which version of the policy went into effect on 19 May 2023?
How often should patients be visited during their hospital stay according to the policy?
How often should patients be visited during their hospital stay according to the policy?
Which of the following is NOT a responsibility of the Patient Experience Manager/Officer during ward rounds?
Which of the following is NOT a responsibility of the Patient Experience Manager/Officer during ward rounds?
What is the next review date for the current policy?
What is the next review date for the current policy?
Which of the following is a focus area for conducting focused conversations during ward rounds?
Which of the following is a focus area for conducting focused conversations during ward rounds?
What should Patient Experience Managers do to prepare for ward rounds?
What should Patient Experience Managers do to prepare for ward rounds?
How can Patient Experience Managers improve client perceptions of hospital facilities?
How can Patient Experience Managers improve client perceptions of hospital facilities?
What level of involvement is expected from Hospital Management regarding Patient Experience roles?
What level of involvement is expected from Hospital Management regarding Patient Experience roles?
What is the significance of establishing clear communication channels during ward rounds?
What is the significance of establishing clear communication channels during ward rounds?
Flashcards
Safety Event Reporting
Safety Event Reporting
A process for identifying, reporting, investigating, escalating, and improving safety events in healthcare settings.
Healthcare Worker (HCW) Notification
Healthcare Worker (HCW) Notification
HCW identifying a safety event must immediately notify their line manager.
Clinical Care Plan
Clinical Care Plan
A plan developed to monitor patient response to interventions following a safety event.
Patient Notification
Patient Notification
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Patient Experience Manager (PxM)
Patient Experience Manager (PxM)
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Safety Event Report
Safety Event Report
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After Action Review (AAR)
After Action Review (AAR)
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Contributing Factors
Contributing Factors
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Just Culture
Just Culture
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Serious Event Management Team (SEMT)
Serious Event Management Team (SEMT)
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Systems Analysis Approach
Systems Analysis Approach
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Patient Safety Manager (PSM)
Patient Safety Manager (PSM)
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Harm Level Categorization
Harm Level Categorization
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Never Event
Never Event
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Near Miss
Near Miss
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Initial Review
Initial Review
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Legal Advice
Legal Advice
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After-Action Review
After-Action Review
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Continuous Improvement
Continuous Improvement
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Incident Categories
Incident Categories
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Multi-Event
Multi-Event
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Yorkshire Contributing Factors Framework
Yorkshire Contributing Factors Framework
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Patient Safety Culture
Patient Safety Culture
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ISBAR
ISBAR
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Healthcare Marketing
Healthcare Marketing
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Digital Marketing in Healthcare
Digital Marketing in Healthcare
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Patient Referral Programs
Patient Referral Programs
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Patient-Centered Services
Patient-Centered Services
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Social Media Marketing in Healthcare
Social Media Marketing in Healthcare
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Search Engine Optimization (SEO)
Search Engine Optimization (SEO)
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Print Media in Healthcare Marketing
Print Media in Healthcare Marketing
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Marketing in Healthcare
Marketing in Healthcare
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Traditional Marketing
Traditional Marketing
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Digital Marketing
Digital Marketing
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Why is Marketing Important in Healthcare?
Why is Marketing Important in Healthcare?
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Direct Marketing
Direct Marketing
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Marketing Mix in Healthcare
Marketing Mix in Healthcare
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What is healthcare marketing?
What is healthcare marketing?
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How does social marketing differ from advertising?
How does social marketing differ from advertising?
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What are the 7 Ps of healthcare marketing?
What are the 7 Ps of healthcare marketing?
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What are the benefits of marketing in healthcare?
What are the benefits of marketing in healthcare?
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What's the role of public relations in healthcare marketing?
What's the role of public relations in healthcare marketing?
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What is the aim of healthcare marketing?
What is the aim of healthcare marketing?
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What are some examples of healthcare marketing strategies?
What are some examples of healthcare marketing strategies?
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What is the importance of patient-centered services?
What is the importance of patient-centered services?
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How can digital marketing be used in healthcare?
How can digital marketing be used in healthcare?
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Why is lean methodology important in healthcare?
Why is lean methodology important in healthcare?
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Direct Marketing in Healthcare
Direct Marketing in Healthcare
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Public Relations in Hospitals
Public Relations in Hospitals
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What is floor supervision's role in patient input?
What is floor supervision's role in patient input?
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Why is patient confidentiality crucial?
Why is patient confidentiality crucial?
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Building trust with patients
Building trust with patients
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Community development events
Community development events
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Cause marketing in healthcare
Cause marketing in healthcare
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Hospital floor managers
Hospital floor managers
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Public relations officers
Public relations officers
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Internal communication training
Internal communication training
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Information Gathering
Information Gathering
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Conducting Visits
Conducting Visits
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Focused Conversations
Focused Conversations
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Feedback
Feedback
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Follow-Up
Follow-Up
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Documentation
Documentation
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Trend Analysis
Trend Analysis
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Ward Round Policy
Ward Round Policy
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What are Ward Rounds?
What are Ward Rounds?
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Who are 'Clients' in a hospital setting?
Who are 'Clients' in a hospital setting?
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What's the role of Patient Experience Managers in Ward Rounds?
What's the role of Patient Experience Managers in Ward Rounds?
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How do Patient Experience Officers contribute to better patient satisfaction?
How do Patient Experience Officers contribute to better patient satisfaction?
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What is the role of a Unit Manager during Ward Rounds?
What is the role of a Unit Manager during Ward Rounds?
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How does Hospital Management contribute to the success of Patient Experience initiatives?
How does Hospital Management contribute to the success of Patient Experience initiatives?
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How often are patients visited during Ward Rounds?
How often are patients visited during Ward Rounds?
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How are Ward Rounds scheduled?
How are Ward Rounds scheduled?
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Study Notes
Initial Management and Reporting of Safety Events
-
Healthcare Worker (HCW) who identifies a safety event must notify their line manager immediately.
-
A clinical care plan is developed to monitor the patient's response to interventions.
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Patient's treating doctor must be notified.
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Patient and/or family must be notified if an event caused harm.
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Patient Experience Manager (PxM) provides feedback to the patient/visitor and/or family.
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Legal advice is obtained prior to engaging with the patient/visitor and/or family.
Reporting of Safety Events
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HCW or immediate Supervisor documents the event in the patient file.
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Reporter completes a Safety Event Report on the Safety Event Management System (short and simple with minimal information).
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Confidentiality must be maintained, no patient, staff, or doctor names are included.
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Reporter classifies the event based on their opinion, using Annexure C for event types.
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Reporters can receive feedback on the event by including their email address.
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Events can be reported anonymously, but must include patient information, hospital/business unit, and location.
Initial Review by Unit/Line Manager and After Action Review (AAR)
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Unit/Line Manager conducts an Initial Review to ensure completeness and correctness of the report.
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A feedback or debriefing session is arranged with staff involved in the event, as well as the rest of the shift, to conduct an After Action Review (AAR).
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AAR identifies gaps and lessons learned, reinforces risk mitigation and prevention measures.
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AAR questions:
- What was supposed to happen? (plan)
- What happened? (Action)
- What was the difference between the plan and the action? (review)
- What can we learn from this? (Personal and collective change.)
- What will you do in the future?
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Unit/Line Manager documents the following on the Safety Event Management System:
- AAR information, especially for Serious harm or death events.
- Contributing factors, as per the Yorkshire Contributing Factors Framework.
First Team Review (All Events)
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Unit/Line Manager reports the event to the Review Team verbally (either immediately or at handover meetings).
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Just Culture principles are adhered to, level of review is determined, and action loop is closed.
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Review Team evaluates if:
- Response and recovery efforts are appropriate.
- Actions to prevent future harm to others are appropriate.
- HCWs involved have received psychological support.
- All contributing factors are identified (as per the Yorkshire Contributing Factors Framework).
Immediate Legal Support
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Advice from the Legal Department is required when there is harm or potential harm to a patient.
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Legal advice is obtained telephonically, ensuring immediate assistance.
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An email is sent to the Legal Department with the event reference number.
Decision for Further Investigation
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Serious harm or death events require a Serious Event Management Team (SEMT) to be established.
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Low harm but repeating events may require an investigation to establish common factors.
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Near misses with significant learning opportunities should also be investigated.
Categorisation of Events
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PSM reviews the safety event report and the Type of Event selected by the reporter.
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PSM determines the correct classification of the event using Annexure D.
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Level of harm is reviewed and changed to the most appropriate level using Table 1.
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This may require engagement with the Unit Manager or HCWs.
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Categorization occurs within 5 working days of the event being reported.
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An initial report using the ISBAR format is completed by the PSM for Serious harm or death events.
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Agency staff must complete the electronic Safety Event Report.
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If no further investigation is required, the event can be "closed" and feedback provided to the reporter if they provided their email.
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Principles for the classification of multiple events:
- Multi-Events occur when more than one individual or a group are impacted by harm.
- Events with the same cause should be investigated individually.
- Common causal factors or associations are identified for improvement.
Patient Safety Event Management Policy
- The policy aims to standardize patient safety definitions and processes for identifying, reporting, investigating, escalating, and improving safety events.
- The policy incorporates definitions of events, an algorithm for classifying event types and harm levels, and a detailed outline of roles and responsibilities.
- The policy establishes protocols for reporting procedures, investigation processes, and notification/escalation pathways for various safety events.
- Specific timeframes are set for completing safety event reports and investigations.
- The policy highlights the importance of continuous improvement activities designed to enhance patient safety and minimize harm.
- A dedicated 'alert' email group and escalation flows for serious events are established.
- The Legal Department is involved to provide advice and guidance on managing matters related to patient harm or potential harm.
Acronyms
- (All acronyms from previous notes are included)
Definitions
- (All definitions from previous notes are included)
Classification of Safety Events
- (All classifications from previous notes are included)
Levels of Harm
- (All harm levels from previous notes are included)
Management of Safety Events
- (All management steps from previous notes are included)
Management and Reporting of Safety Events
- (All management and reporting steps from previous notes are included)
Key Takeaways
- (All key takeaways from previous notes are included)
Safety Event Management System
- (All information about SEMS from previous notes are included)
Reporting Safety Events
- (All reporting instructions from previous notes are included)
Categorization & Classification
- (All categorization and classification instructions from previous notes are included)
Investigation
- (All investigation steps from previous notes are included)
Review & Root Cause Analysis
- (All review and root cause analysis steps from previous notes are included)
Action Plans and Continuous Improvement
- (All action plans and improvement steps from previous notes are included)
Communication & Feedback
- (All communication and feedback steps from previous notes are included)
Monitoring and Continuous Improvement
- (All monitoring and improvement steps from previous notes are included)
Never Events
- (All never events information from previous notes are included)
Maternal and Neonatal Events
- (All maternal and neonatal event information from previous notes are included)
Healthcare-Associated Infections (HAIs)
- (All HAI information from previous notes are included)
Patient Safety Event Management Policy
- (Patient safety event management information from previous notes is included)
Incident Categories
- (All incident categories from previous notes are included)
Reporting Requirements for Medical Safety Events to the Office of Health Standards Compliance (OHSC)
- (All OHSC reporting requirements from previous notes are included)
Reporting Requirements to Other Organizations
- (All other reporting requirements from previous notes are included)
Population Concepts
- (All population concept information from previous notes is included)
Population Growth Rates
- (All population growth rate information from previous notes is included)
Infant Mortality Rates
- (All infant mortality rate information from previous notes is included)
Life Expectancy
- (All life expectancy information from previous notes is included)
Other Factors Influencing Population Growth
- (All other population growth influences from previous notes are included.)
Conservation
- (All conservation information from previous notes is included)
Ecological Reasons for Conservation
- (All ecological reasons for conservation from previous notes is included)
Economic Reasons for Conservation
- (All economic reasons for conservation from previous notes is included)
Aesthetic Reasons for Conservation
- (All aesthetic reasons for conservation from previous notes is included)
Ethical Reasons for Conservation
- (All ethical reasons for conservation from previous notes is included)
Threats to Conservation
- (All threats to conservation information from previous notes are included)
Conservation Areas in South Africa
- (All conservation area information from previous notes is included)
Types of Conservation Areas in South Africa
- (All types of conservation area information from previous notes are included)
Other Types of Conservation Areas in South Africa
- (All other types of conservation areas information from previous notes are included)
Areas of Conservation Focus in South Africa
- (All areas of conservation focus information from previous notes are included)
How to Help with Conservation
- (All ways to help conservation information from previous notes are included)
Conclusion
- (All conclusions from previous notes are included)
Technical/Medical Equipment Events
- (Technical/medical equipment events information from previous notes is included.)
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Description
This quiz covers the essential procedures for the initial management and reporting of safety events in healthcare settings. It highlights the responsibilities of healthcare workers, the importance of communication with patients and families, and the steps involved in documenting and reporting events. Understanding these protocols is crucial for maintaining patient safety and confidentiality.
