Patient Safety
What two successive campaigns did the Institute for Healthcare Improvement launch in 2005-2006 and 2006-2008?
(1) 1,000 Lives Campaign (2) 5 million Lives Campaign
What 2 things did Congress pass in response to the reports published by the Institution of Medicine in 1999 and 2003?
(1) AHRQ (2) Patient Safety and Quality Improvement Act
Name the 5 Moments of Hand Hygiene.
(1) Before patient contact. (2) Before a aseptic task (3) After body fluid exposure (4) After patient contact (5) After contact with patient surroundings
Name 4 ways that you can play a role in quality and safety.
(1) Being an effective team player (2) Practicing effective communication (3) Applying an attitude of assertive inquiry and advocacy (4) Being aware of potential safety risks (situational awareness)
Name 3 main ways harm to patients can occur.
(1) Errors due to violation in practice (2) Neglecting to provide an essential service (3) Providing a service that isn't needed
Harm to patients can stem from not providing enough information about:
(1) How to take their medications (2) Potential adverse effects from procedures or medications (3) When to contact their medical provider (4) Signs and symptoms that are normal vs. abnormal (5) Other options to address their health issue
Name 3 departments that the Quality and Safety Department of a hospital often works closely with.
(1) Material Management: to ensure supplies distributed throughout the hospital are safe and effective and remained stocked. (2) Biomedical Equipment: to ensure that the equipment used throughout the hospital remains in good working condition and is available when needed. (3) Patient Relations Department: to address any patient or family concerns about safety.
Name 5 institutions that recognize the importance of patient safety.
(1) National Academies of Science (2) American Nurses Association (3) American Academy of Nursing (4) Agency for Healthcare Research and Quality (5) Joint Commission
List 7 factors that effect patient safety.
(1) Organization and management factors (2) Work environment factors (3) Team factors (4) Task factors (5) Individual factors (6) Patient characteristics (7) External environment factors
What does the bundle approach include bundles to do?
(1) Prevent Central-Line Associated Bloodstream Infection (2) Prevent Obstetrical Adverse Events (3) Prevent Ventilator-Associated Pneumonia (4) Sepsis Bundles
Name 3 long-term goals related to patient safety that are identified by the National Quality Strategy.
(1) Reduce preventable hospital admissions and readmissions (2) Reduce the incidence of adverse healthcare associated conditions (3) Reduce harm from inappropriate or unnecessary care
Name 4 skills of effective team members in healthcare.
(1) Reliable (2) Offer constructive communication (3) Good problem-solving skills (4) Accountability
Name 4 measures that have been used to help improve patient safety and reduce healthcare-related infections.
(1) Standard precautions and personal protection methods (2) Sharps disposal system (3) Immunizations for patients and healthcare workers (4) Reducing time of invasive catheters (urinary, respiratory, and blood)
List 4 individual patient factors to consider when administering medication.
(1) allergies (2) comorbidities (3) drug interactions (4) pregnancy
What 3 categories is a culture of safety build around?
(1) creating reliable team interactions (2) strengthening reliable design processes (3) promoting the value of a just culture
Name two categories of errors in relation to patient safety.
(1) errors of commission (2) errors of omission
Give 3 common examples of errors of commission.
(1) not administering a preoperative antibiotic as prescribed (2) ordering a medication for a patient who has a documented allergy to that medication (3) prescribing or administering a preoperative antibiotic using the wrong dose, route, or timing
Name 2 analytical methods that are commonly employed to understand how errors occur and clinical risk.
(1) retrospective (2) prospective
Name the 6 rights of verification.
(1) right patient (2) right drug (3) right dose (4) right route (5) right time (6) right documentation
List 5 pertinent questions regarding medication.
(1) verification of all medications on list (2) verification of dose (3) the reason for prescription (4) whether they are taking it as prescribed (5) verification by pharmacist (added)
How many never events are there currently? And what are the 6 categories that they are grouped into?
29; surgical, product or device, patient protection, care management, environmental, radiological, and criminal
What did the World Health Organization implement to help remind healthcare workers about when to perform hand hygiene?
5 Moments of Hand Hygiene
Who was the National Quality Strategy first published by in 2011?
AHRQ
AHRQ
Agency for Healthcare Research
Legislation that mandates an annual report on the status of patient safety.
Agency for Healthcare Research (AHRQ)
How does patient safety seek to prevent medical errors?
By equipping healthcare teams with tools to improve quality, safety, and efficiency.
Who initiated the bundle approach to improve the implementation of evidence based processes?
Institue for Healthcare Improvement
What institution launched two successive campaigns to raise awareness and provide tools to significantly reduce morbidity and mortality in the American Healthcare system?
Institute for Healthcare Improvement
This healthcare model for improvement is focused on setting aims, establishing measures, selecting changes, and then testing changes. After testing the change on a small scale, the change is refined and implemented on a more broad scale.
Institute for Healthcare Improvement's Model for Improvement
What program is directed toward improving patient education and patient-provider communication as well as highlighting the issue of medication safety?
Joint Commission Speak Up Initiatives
A Six Sigma process improvement methodology that removes inefficiencies in care provided.
Lean
What provides a framework for the national goals of patient safety?
National Quality Strategy
This act promotes shared learning to enhance quality and safety nationally.
Patient Safety and Quality Improvement Act
What report did the Institution of Medicine publish in 2003 that recommended standardization and better management of information on patient safety?
Patient Safety: Achieving a New Standard of Care
Name a common communication technique that was implemented to help prevent errors.
Situation-Background-Assessment-Recommendation (SBAR)
A measurement based strategy for process improvement and problem reduction through application of improvement projects.
Six Sigma
Since 2001, what is every hospital required to have by the Joint Commission?
Someone designated to carry out safety responsibilities
A landmark report made by the Institution of Medicine in 1999 that highlighted patient safety by the fact that 98,000 deaths were being caused each year in the United States by medical errors.
To Err is Human
What is the main goal of patient safety?
To reduce potential harm in all areas of healthcare.
What initiatives are used to help improve patient safety during invasive procedures and surgeries?
WHO Surgical Safety Checklist: (1) 19-item checklist (2) Joint Commission Universal Protocol (3) Conduct a pre-procedure verification process (4) Mark the procedure site (5) Perform a time-out to verify correct patient identity, correct site, and correct procedure to be performed
What does the Safety Officer of a hospital often lead?
a Quality and Safety Department
Injury caused by medical care.
adverse event
This entails looking out for the well-being of the patient and family, and may include speaking up to ensure that their preferences are acknowledged and their needs are met.
advocacy
What does good communication remove?
assumptions
This kind of attitude involves using your skills of critical thinking to question and double-check the actions that you and other team members are take on a daily basis to ensure that patient care is being carried out in a safe and efficient manner. This includes asking questions and keeping an open mind to alternative ways of conducting patient care.
attitude of injury
Improving communication among team members, providing opportunities to strengthen leadership skills, and giving mutual support are all apart of...
creating reliable team interactions
The failure of a planned action to be completed as intended or the use of a wrong plan to achieve a aim.
error of commission
This kind of patient safety error results from not taking action.
error of omission
A prospective method based on an engineering approach that is usually applied in the early stages of developing a new product.
failure modes and effects analysis (FMEA)
This method of analysis seeks to anticipate and prevent adverse events through safety designed by imagining all the scenarios that may lead to potential failures and adverse events. Designs are then adjusted to reduce the likelihood of error.
failure modes and effects analysis (FMEA)
True or false? Medication safety does not extend beyond the healthcare setting into the home.
false; it does
What should be present to help people understand the importance of sharing the safety information and the impact it made on improving the system and patient care?
feedback loop
A culture that supports and encourages open and honest reporting of medical errors without fear of retribution.
just culture
What should be verified with clear information provided to the patient before transitions in care or discharge?
medication list
A process that should take place at the initiation of each patient interaction to ensure that a medications list is updated and accurate.
medication reconciliation
This aspect of safety considers adverse events that occur in prescribing medications as well as administration whether it is given by a healthcare provider or patient.
medication safety
An event that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention.
near miss
A serious adverse event that is clearly identifiable and measurable, and usually preventable.
never event
What plays a large role in fostering patient safety by building a culture of safety and transparency, supporting systems of continuous quality improvement and safety review and implementing policies and procedures to help prevent or resolve issues of safety.
organization and management
The prevention of harm to patients.
patient safety
A formal analysis of performance and systematic efforts in order to improve the quality of healthcare.
quality improvement
The retrospective analysis of what went wrong when an adverse event occurred.
root cause analysis (RCA)
What kind of analysis is based on the preface that cause of an adverse event is the end result of multiple system failures?
root cause analysis (RCA)
What kind of analysis seeks to identify and understand all contributing causes to an adverse event through review of data and interviews, in order to redesign the systems to make them safer in the future?
root cause analysis (RCA)
An unexpected occurrence involving death or serous physical or psychological injury, such as an operation on the wrong patient or amputation of the wrong limb.
sentinel event
Results in the death or loss of a body part, disability or loss of body function.
serious event
Being alert to factors that may contribute to adverse events, such as work overload, distractions, interruptions, and fatigue.
situational awareness
This component of patient safety focuses on processes of patient care, such as systems built around standardization of care.
strengthening reliable design processes
Failures of design and failures of organization and environment.
system factors
This kind of redesign is based on patient needs to care as effectively as possible.
systematic design
What has fostered global awareness for patient safety?
the World Health Organization's "World Alliance for Patient Safety"
True or false? Adverse events can occur without the presence of error.
true
True or false? Patient safety is one of six national priorities.
true
True or false? There is a continuum between quality and safety.
true
The act of doing something that is not allowed by rule or law.
violation
Should you have a standard pattern to follow before administering medications to help identify potential risks?
yes
