Improving Patient Safety in Healthcare, Exams of Clinical Medicine

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According to WHO, in developed countries worldwide, what is the approximate likelihood that a hospitalized patient will be harmed while receiving care? ✔✔10% According to WHO, in developed countries up to 10 percent of hospital patients may be harmed while receiving care. Since the publication of To Err Is Human in 1999, the health care industry overall has seen which of the following improvements? ✔✔Wider awareness that preventable errors are a problem More than a decade after the publication of To Err Is Human, there is now wide recognition throughout health care that the number of errors is way too high. Although this awareness has not yet led to consistently lower rates of preventable medical error, progress is being made. Health care organizations have begun to realize and accept that most errors cannot be linked to the performance of individuals, but rather to the systems in which they function.

Patient Safety: IHI PS 101 Introduction toPatient Safety with verified

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Safety has been called a "dynamic non-event" because when humans are in a potentially hazardous environment: ✔✔It takes significant work to ensure nothing bad happens The best answer is it takes significant work to ensure nothing bad happens. When things go right in a potentially hazardous environment, nothing bad happens. But in order for this "non-event" of nothing going wrong to occur, a lot of things must be done right. Thus, safety has been described as a "dynamic non-event." To prevent this type of error from recurring in this unit, which of the following is MOST important? ✔✔An improved culture of safety and teamwork Had there been a culture of safety fostering better teamwork, this error may well have been prevented. In this case, when James asked Maria for help, she made him feel bad instead of being a team player. In this type of environment, James may be reluctant to ask for help, even if he is more closely supervised. We can generally assume that health care providers do not want to harm their patients, so the threat of punishment is not the best way to prevent mistakes. Although errors may occur when there is no recognized best practice, in the case of IV fluid replacement, clear recommendations do exist. Who is likely to be negatively affected by this medical error? ✔✔All of the above

The best answer is all of the above. Patients and families are not the only ones affected when a medical error occurs. In this case, James is likely to be devastated, and Maria may be affected as well. Some providers even leave their profession after committing errors leading to a death. One hospital CEO insists on including performance data in the hospital's annual report. "We do very well on most measures, except for one or two, but we put those in anyway," she says. "We want to hold ourselves accountable." Does this practice demonstrate effective or ineffective leadership? ✔✔Effective leadership: Being transparent, even about poor results, is a mark of a good leader. Good leaders know that leaders are highly visible — and they therefore set examples for others. A leader who seeks transparency in her followers must demonstrate the same quality herself. This appears to be an example of which of the following? ✔✔Unfair attribution of blame Although multiple providers were involved in these near-misses and mistakes, only one provider was asked to leave. This is not fair, because others clearly could have made (and did make) the same mistake, suggesting the problem was based in a system error rather than reckless behavior by an individual.

A nurse who realized that his colleagues weren't consistently following up on patient results reported the problem to the clinic leadership right away. Which response would be most consistent with a culture of safety? ✔✔Investigating the problem and seeking systems solutions The best answer is investigating the problem and seeking systems solutions. An organization must develop a method to surface and learn from defects and harm that occurs to patients. We know that incident reports are one way to learn. They can also be an indicator of the culture of the organization. That is the more people are willing to report, the safer they feel. Why is psychological safety a crucial component of a culture of safety? ✔✔It allows people to learn from mistakes and near-misses, reducing the chances of further errors. In psychologically safe environments, people understand that making mistakes is rarely a sign of incompetence, and that they won't be judged for discussing mistakes. Because of that, people are able to call out errors - whether their own or others' - and improve the processes that made the errors possible. What is most likely to happen if a health system punishes an individual for an unintended error that was the result of a systems problem? ✔✔A and C

Punishing individuals for blameless errors has a weakening effect on a health system's culture of safety (an environment in which providers can discuss errors and harm openly because they know they won't be unfairly punished and have confidence that reporting safety events will lead to improvement). Staff may view the punishment as unfair, and worry that they will be punished if they make an error. This fear decreases the chances of staff reporting errors so that the system can learn from them. Staff trying to be more careful will ultimately not eliminate errors caused by faulty systems. Which of these is a behavior providers should adopt to improve patient safety? ✔✔Follow written safety protocols, even if they slow you down. Safety protocols are in place for a reason, and you should follow them, even if they slow you down. Sometimes there will be a problem with a policy or procedure, in which case you should report it, rather than inventing a "workaround" (a method to circumvent a problem without fixing it). Likewise, you should speak up if you believe any colleague — supervisors included — is threatening patient safety. Part of patient-centered care is respecting patient autonomy, even if it means considering different treatment approaches than what you would normally consider "best practice."

Which of the following should you keep in mind as your hospital redesigns the way it handles knee replacements? ✔✔How system components are integrated with one another is as important as how well they function independently. Any complex design process should begin with excellent component processes and materials. But such components will not, by themselves, result in an excellent overall result. How components (and component processes) are integrated is a key to overall outcomes. This is as true for a medical care process as it is for an industrial design process. Even with a committed multidisciplinary team, it is very rarely, if ever, possible to get everything right on the first try. Finding flaws after initial implementation (and opportunities for further improvement) should be expected and embraced. While commitment to innovation, excellence, and continual improvement should be supported from the very top of an organization, the actual leadership of the design process should be at the level that will serve best to engage those who have the deepest knowledge of the workflows and component activities, and can engage the multidisciplinary design team. Which of the following is typically true of "weak signals"? ✔✔They can combine with other human or environmental factors to result in catastrophe. Weak signals that could be used to identify system deficiencies are common — and usually ignored. This is understandable since, by themselves, such signals do not result in direct harm. It

is only when they combine with other factors that harm (and sometimes catastrophe) results. Examples in and out of health care abound, including NASA's Columbia Space Shuttle disaster, which, if the response to such signals had been more robust, could have been prevented. Since weak signals occur in daily work at all levels of an organization, each individual must see it as part of his or her job to identify and respond to such signals (or to "escalate" the problem up the hierarchy so that it can be fixed). The term "normalized deviance" refers to: ✔✔Acceptance of events that are initially allowed because no catastrophic harm appears to result. Paradoxically, the fact that weak signals do not result in harm is what makes them most dangerous. When a weak signal is ignored (perhaps many times) and no harm results, workers integrate it into their conception of what is normal. Statements like "we always do it that way" may indicate underlying complacency. This acceptance of unsafe, ineffective, or inefficient routines is called normalized deviance. You meet with the nurse administrator responsible for improvement when issues in the process of care are identified by those on the wards. She listens carefully to your concern, but in the end says she can only try to help improve nursing issues, and not those that extend to pharmacy or transport. The primary reason your meeting is unlikely to lead to an adequate solution is: ✔✔The

nurse administrator did not have the appropriate span of responsibility to engage the system components needed to solve the problem. Steve Spear identifies a number of steps needed to fix problems in a production system. They include recognizing abnormalities; having an identified person to call, with the knowledge, attitude, and responsibility necessary to find a solution; and giving workers the time and resources to solve the problem. In the case of health care, this means treating the "system" as well as the "patient." The challenge here is that even though someone is designated, and that person may have the time to fix how work is done, the nurse administrator may not have the perspective and authority to work across boundaries of specialty, function, and discipline.