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27 Cards in this Set

  • Front
  • Back
patient Safety
freedom from accidental injury involves the establishment of operational systems and processes that minimize the likelihood errors and max the likelihood of seizing them early enough when they occur.
Error: may or may not result in injuries or death.
the failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to acheive an aim (error of planning)
Adverse Events:

resulted injuries or death.
an injury caued by medical management rather than by the underlying disease or condition of the patient. (preventable and negligent)
Types of Error
1. Treatment: error in the dose or method of using a drug.
2. preventive: failure to provide prophylactic tx.
3. Diagnostic:
- failure ot act results of monitoring or testing.
Active Error:
- occur at the frontline and their effects are felt almost immediately.
Latent Error:
- NOT frontline error, include poor design, incorrect instillation, faulty maintance,
Human FActor:
- interrelationships between:
1. humans
2. tools
3. enviroment in which they work and live.
What are examples of errors of execution:
- slips (observable)
- lapses (not observable)
Error of planning
Two major approaches for human factors improvement?
- Critical incident analysis system failure = latent error.
- Naturalistic decision making: uncovers the factors weighed and the processes used in making decisions when faced with ambigious information under time pressure.
Errors of commission
- administration of improper drug
Errors of omission:
- failure to administer a drug that was prescribed.
Medication use process:
1. Prescribing
2. Dispensing
3. Administering
4. Monitoring
5. Systems and Management Control
Prescribing Errors include:
1. knowledge of drug therapy.
(renal or hepatic dysfunction)
2. knowledge regarding pt
that affect drug therapy (history of allergy)
3. use of calc, decimal points, unit and rate .
4. incorrect drug name, dosage form, or abb.
The accident:
The Error:
Accident: breakdown in the I.V. medication delivery system during surgery.
Error: free flow of the medication from the infusion device.
Hindsight bias:
- perception after the fact: things that were not detected at the time of the accident seem obvious in retrospect.
Confirmation bias:
- this involve individual who would see what he/she want to see the way he/she see it; evidence point out the contrary can't be seen since the individual is so involved in what he/she is so familiar with.
Patient Saftey - Standard:
A MINIMUM level of acceptable performance or results or EXCELLENT levels of performance or results or the RANGE of acceptable performance or results.
Standards used to define a:
process or an outcome.
Quality of Care:
- degree to which health services for individuals and pop. increase teh likelihood of desired health outcomes and are consistent with current professional knowledge.
Regulators and accreditors:
- a role in creating a safe enviroment for patients:
~ require pt. safety prog.
1. Set up time for implementation.
2. Accountability
Public and Private Health Care Purchasers:
1. Consider pt safety issues in their contracting decisions.
2. Provide on-going pt safety info to their customers.
3. Communicate concerns about pt. safety to the accrediting bodies.
CDER mission:
- to assure that safe and effective drugs are available to american people.
FDA authority - Pre - Approval Drug
The CDER has the statuary authority to impose a clinical hold on a trial if: agency "does not believe or cannot confirm" that the study can be conducted w/o unreasonable risk to the subjects/patients.
Mandatory Reporting Systems:
Reporting systems whose primary purpose is to hold providers accountable for serious patients injuries or death.
What is the mandatory reporting system purpose?
1. Assuring the public that the most serious errors are reported and investigated and appropriate follow-up action is taken.
2. Provide an incentive to health care organizations to improve patiet safety in order to avoid potential penalities and public exposure.
3. Require all health care org. to make some level of investment in patient safety.
Voluntary Reporting System:
Primary purpose: patient safety improvement.
The system serves to IDENTIFY and REMEDY vulnerabilities in systems before the occurence of harm.