Patient Safety 1

Front 1

patient Safety

Back 1

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.

Front 2

Error: may or may not result in injuries or death.

Back 2

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)

Front 3

Adverse Events:

resulted injuries or death.

Back 3

an injury caued by medical management rather than by the underlying disease or condition of the patient. (preventable and negligent)

Front 4

Types of Error

Back 4

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.

Front 5

Active Error:

Back 5

- occur at the frontline and their effects are felt almost immediately.

Front 6

Latent Error:

Back 6

- NOT frontline error, include poor design, incorrect instillation, faulty maintance,

Front 7

Human FActor:

Back 7

- interrelationships between:
1. humans
2. tools
3. enviroment in which they work and live.

Front 8

What are examples of errors of execution:

Back 8

- slips (observable)
- lapses (not observable)

Front 9

Error of planning

Back 9

mistakes.

Front 10

Two major approaches for human factors improvement?

Back 10

- 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.

Front 11

Errors of commission

Back 11

- administration of improper drug

Front 12

Errors of omission:

Back 12

- failure to administer a drug that was prescribed.

Front 13

Medication use process:

Back 13

1. Prescribing
2. Dispensing
3. Administering
4. Monitoring
5. Systems and Management Control

Front 14

Prescribing Errors include:

Back 14

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.

Front 15

The accident:
The Error:

Back 15

Accident: breakdown in the I.V. medication delivery system during surgery.
Error: free flow of the medication from the infusion device.

Front 16

Hindsight bias:

Back 16

- perception after the fact: things that were not detected at the time of the accident seem obvious in retrospect.

Front 17

Confirmation bias:

Back 17

- 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.

Front 18

Patient Saftey - Standard:

Back 18

A MINIMUM level of acceptable performance or results or EXCELLENT levels of performance or results or the RANGE of acceptable performance or results.

Front 19

Standards used to define a:

Back 19

process or an outcome.

Front 20

Quality of Care:

Back 20

- degree to which health services for individuals and pop. increase teh likelihood of desired health outcomes and are consistent with current professional knowledge.

Front 21

Regulators and accreditors:

Back 21

- a role in creating a safe enviroment for patients:
~ require pt. safety prog.
1. Set up time for implementation.
2. Accountability

Front 22

Public and Private Health Care Purchasers:

Back 22

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.

Front 23

CDER mission:

Back 23

- to assure that safe and effective drugs are available to american people.

Front 24

FDA authority - Pre - Approval Drug

Back 24

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.

Front 25

Mandatory Reporting Systems:

Back 25

Reporting systems whose primary purpose is to hold providers accountable for serious patients injuries or death.

Front 26

What is the mandatory reporting system purpose?

Back 26

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.

Front 27

Voluntary Reporting System:

Back 27

Primary purpose: patient safety improvement.
The system serves to IDENTIFY and REMEDY vulnerabilities in systems before the occurence of harm.