Patient Safety Exam 2
culture of patient safety
the culture of an organization that focuses on the safety of the care that is delivered
premature closure
the decision to focus on only 1 diagnosis comes from many different causes
human factors engineering
the discipline that attempts to identify and address safety problems that arise due to the interaction between people, technology, and work environments
availability heuristic
the doctor thinks of what easily comes to mind based on some but not necessarily all the symptoms and clinical findings
mindfulness meditation
awareness of feelings either good or unpleasant and the development of capacity to lower one's reactivity to these feelings and avoid judgements about these feelings
red rules
rules that must be followed to the letter. Any deviation from these will bring work to a halt until compliance is achieved; in addition to relating to important and risky processes , must also be simple and easy to remember
communication, lack of standard system, lack of training, missing information, physical, lack of time, large number of patients
seven examples of barriers for effective handoffs
develop behavior based expectations, instill consistent work habits, hold each other accountable, measure and address errors, provide correct action and follow up
seven ways that patient safety can be improved through an educational process
fatigue
weariness and depleted energy
rapid response team
when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside to immediately assess and treat the patient with the goal of preventing adverse clinical outcomes
catheter associated urinary tract infection
CAUTI stands for this
central line associated blood stream infection
CLABSI stands for this
sick, identifying data, general hospital course, new events, overall health status, upcoming possibilities, tasks to complete
SIGN OUT stands for this; handoff technique
swiss cheese model of error
a model that illustrates how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safety barrier or precaution relevant to a particular hazard
communication and optimal resolution
a process that health care institution and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause possible harm
burnout
a syndrome of 1) depersonalization 2) emotional exhaustion and 3) poor personal accomplishment associated with decreased work performance
failure mode effective analysis
a team based systematic and proactive approach for identifying the ways that a process can fail, why it might fail, the effects of that failure and how it can be made safer
event reporting
also known as incident reporting; ubiquitous system in hospitals
close calls
also known as near misses; an error that doesn't cause any harm but only because of chance
sentinel event
an adverse event in which death or serious physiological harm to a patient has occurred; it is usually used to refer to events that are not at all expected or acceptable
root cause analysis
an approach commonly used in health care to understand errors and accidents after they occur; asking what happened, why did it happen, and what can be done to prevent it from happening again.
Team STEPPS
an evidence-based set of teamwork tools aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals
high reliability organization
an organization that carries out intrinsically complex and hazardous work but achieves consistently safe and effective performance
anchoring
cognitive heuristic error type in which event likelihood is based on starting point
representative
cognitive heuristic error type in which the event likelihood based on resemblance to other well defined events
disclosure
communication to the patient and as appropriate to the family concerning what is known about a serious unanticipated outcome
systems thinking
complexity theory differs from this by emphasizing the interaction between local systems and their environment
resilience
connections to colleagues, patients and the profession is fundamental to maintaining this
lean theory
critically examines processes to reduce wasteful activities that add no value for the patient
appreciative inquiry
discussion of techniques that help one work through difficult clinical situations; use of listening and telling stories
sleepiness
drowsiness and decreased alertness
handoffs
due to the limitation of work hours, there was an increase in these, which suggested worse patient outcomes
checklists, computer assisted care, communication techniques, red rules, standardization, teamwork, accountability, rapid response teams, review of infrastructure, near misses, root cause analysis
eleven aspects that helped to improve patient care
rule based error
error type that refers to errors in algorithms, formulas, experiential do's/don'ts; examples include treatment protocols, checking allergies before medications, etc.
skill based error
error type that refers to errors in tasks that are simple, familiar, routine, straightforward and repetitive; examples include taking phone messages, getting gas, etc.
knowledge base error
error type that refers to errors in unknown, unfamiliar, or new situations; examples include finding a lost object with unknown owner
device related errors
errors that occur due to the medical equipment malfunctioning; cardiac pacemaker errors
monitoring errors
errors that occur when the caretaker does not observe a red flag; examples include alert fatigue and drug monitoring
patient identification errors
errors that occur when the wrong patient is treated; improved transfusion process by bar coding, using 2 patient identifiers and verbal confirmation of lab results
large volume, receive results after patient has left, paper based filing, no context
examples of what makes lab results difficult to receive in outpatient care
affective bias
feelings for/against a patient that colors one's approach toward the patient
shift change, day to night call, unit to unit, laboratory and imaging tests, and hospital discharge
five examples of types of handoffs
time limitations, implicit assumptions, authority gradients, diffusion of responsibility, and handoff information
five factors that contribute to medical decision making errors
Care for the caregiver
following serious, unintentional harm due to systems failures and/or errors that resulted from human performance failures, the involved caregivers should receive timely and systematic care
phonetic protocol
for all consonants say a word that sounds like the letter; for example Z as in zebra
numeric protocol
for all two digit numbers say the numbers separately; for example 1, 5 instead of fifteen
read/repeat back, SBAR, numeric protocols, ask questions
four communication techniques that allow HCWs to do so clearly
quantitative work overload, deficiency in work related role models, deficiency in job resources, emotionally demanding situations
four examples of occupational factors that lead to burnout
acknowledgment of the high-risk nature of an organization's activities, a blame-free environment where individuals are able to report errors, encouragement of collaboration across ranks and disciplines, organizational commitment
four key features to building a culture of safety
Stop, think, act, review
four steps that can be taken to combat slips or lapses associated with skill based errors
action, assertion, adherence, and memory
four ways in which patients can cause medical errors to occur
provide protected time for learners to share concerns, acknowledge and appreciate all learners by sharing a life story, develop mentoring networks, provide maximal patient engagement
four ways to protect against burnout
incident reporting
frequently used as a general term for all voluntary patient safety event reporting systems, which rely on those involved in events to provide detailed information.
just culture
holds the individuals to account for reckless behavior while also recognizing that people make mistakes and aren't responsible for systems; people feel comfortable disclosing error, including their own
triple aim
improving the health of the population, enhancing the care and outcomes of the patient and reducing per capita health costs
situation, background, assess and recommendation
in SBAR, these four steps are taken to communicate effectively regarding a patient; used in urgent situations
ask, request, concern, chain of command
in this model, a subordinate can communicate when they believe an error has occurred effectively to a superior
systems approach
medicine has traditionally treated quality problems and errors as failings on the part of individual providers, this approach takes the view that most errors reflect predictable human failings in the context of poorly designed systems; identifies situations or factors likely to give rise to human error and implements system changes that will reduce their occurrence or minimize their impact on patients
individual factors
men, white, younger, unmarried, family related stress, dissatisfaction, spouses that work too much or too little, neuroticism, residents whose fathers were not doctors, non-parent, lower agreeableness, poorer health, mood disturbance, somatic complaints, alcohol abuse, anxiety are examples of this
knowledge base error
most common error type made in hospitals
prevent infection
national patient safety goal that has been improved substantially by limiting ventilator, central line, and urine catheter infections
use medicines safely
national patient safety goal that has been improved substantially by using pop up drug interactions
prevent mistakes in surgery
national patient safety goal that has been improved substantially by using surgery checklists and time outs
identify patient safety risks
national patient safety goal; find out which patients are most likely to try to commit suicide
use medicines safely
national patient safety goal; includes before a procedure, label medicines that are not labeled; take extra care with patients who take medicines to thin their blood; record and pass along correct information about a patient's medicines
improve staff communication
national patient safety goal; includes get important test results to the right staff person on time
use alarms safely
national patient safety goal; make improvements to ensure that alarms on medical equipment are hear and responded to on time
prevent mistakes in surgery
national patient safety goal; make sure that correct surgery is done on the correct patient and correct place on the patient's body; mark the correct place on the patient's body where the surgery is to be done
identify patients correctly
national patient safety goal; requires that at least two way to identify patient is used when care is being given
prevent infection
national patient safety goal; use the hand cleaning guidelines from the centers for disease control and prevention or the World Health Organization; use proven guidelines to prevent infections that are difficult to treat, from central lines, after surgery, and a result of catheterization
depersonalization
one of the metrics of Maslach Burnout Inventory; negative, cynical, detached response to other people
personal accomplishments reduction
one of the metrics of Maslach Burnout Inventory; one feels less competent with one's work
emotional exhaustion
one of the metrics of the Maslach Burnout Inventory; overextended and depletions of one's emotional resources
mindfulness
one way to combat burnout is through this; can be done through meditation or narrative
transparency
openly providing information about the safety and quality of care with staff, partners, patients and families
15.6%
percentage of US college educated 22-34 year olds that met criteria for alcohol abuse/dependence
32.4%
percentage of medical students that met criteria for alcohol abuse/dependence
60%
percentage of physicians that report burnout
timeout
planned periods of quiet and/or interdisciplinary discussion focused on ensuring that key procedural details have been addressed.
complexity theory
provides an approach to understanding the ways in which some adaptive systems produce novel behavior not expected from the properties of their individual components
QV and V
questioning attitude technique; steps include qualify the source of info, validate the info with one's own abilities and experiences, and verify with a second source
computerized physician order entry
refers to any system in which clinicians directly place orders electronically with the orders transmitted directly to the recipient; ensure legible orders and have the potential to sharply reduce medication prescribing errors
planned redundancy, stress reduction, shift time limits to reduce human error, reduce number of handoffs, test tracking, and explicit rules for when to contact ordering provider
six ways that handoffs can be improved in the hospital setting
six sigma
striving for near perfection in the performance of a process; derived from the Greek letter describing the standard deviation from the norm; targets a defect rate of < 3.4 per million opportunities
never event
term introduced by the national quality forum to refer to 29 types of medical errors; identified as being so serious and preventable that they should never happen
patient, plan, purpose, problems and precautions
the five p's in a handoff
medication reconciliation
the process of avoiding medication inconsistencies that occur with the transfer of care by reviewing the patient's current medication regimen and comparing it with the regimen being considered for the new setting of care
handoff
the process when one health care professional updates another on the status of one or more patients for the purpose of taking over their care
medical errors
these were not necessarily reduced with a reduction in work hours
center for medicare and medicaid services
this federal program pays hospitals and physicians for services rendered
sleep hygiene
this improved for residents when the work week was reduced
expert source
this is the corrective action for a knowledge base error
Joint Commission
this national group accredits healthcare organizations
think twice before breaking a rule
this should be done to fix rule based errors; rule based errors occur because others believe rules are meant to be broken, rules are used incorrectly, or the incorrect rule is chosen for a given situation
education
this was negatively impacted for residents when the work week was reduced
highest priority, simple action, limited number
three characteristics of red rules
cognitive and motor skill deteriorate, impairment equal to alcohol consumption and increased risk of MVAs
three ramifications of the medical student and physician fatigue, stress and burnout
premature closure
using an availability heuristic may lead to this
VAP
ventilator associated pneumonia
narrative medicine
write stories about personal experience on topics such as burnout and self care
