Patient Safety and Quality Improvement in Healthcare, Exams of Medicine

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Patient Safety and Quality Improvement

in Healthcare

LT: Principles and applications of patient safety and quality improvement - ✔ANS: What is the flow (3 steps) in achieving high reliability in healthcare? - ✔ANS: 1) collective mindfulness- everyone is searching for changes that may lead to failure ✔2) quality improvement- eliminate deficiencies by using QI processes ✔3) Patient safety- a safety culture develops by demanding sustained performance How many Americans are estimated to die as result of medical error - ✔ANS: 44,000-98000 so 50.000- What number does it rank in leading causes of death - ✔ANS: 8th Describe the accident causation model - ✔ANS: starts on left with management decisions/organizational processes, then work environment factors/team factors/ patient factors, then moves to unsafe acts/errors/violations, then through the defense barriers leading to the accident describe the Swiss cheese model - ✔ANS: average of 5 mistakes that could have been prevented, leads to holes in the system and things get through. Latent errors pose the greater threat in the complex What is an error of execution? - ✔ANS: a correct action doesn't proceed as intended, ie right medicine order but doesn't get received

what is an error in planning? - ✔ANS: original intended action is not correct, ie a medication shouldnt have been given What are the 5 principles to design safe health care? - ✔ANS: 1) provide leadership ✔2) respect human limits in process design ✔3) promote effective team functioning ✔4) anticipate the unexpected ✔5) create a learning environment How can human factors be made better in health care? - ✔ANS: - study the factors that make it easier to do work in the right way -based on principles designed to compensate for human cognitive failings (standardization, simplification, use of protocols and checklists) What are the levels of patient safety culture? - ✔ANS: Level A-E, Ohio health is at a D A=pathologic (no interest in getting better) B=reactive (take safety serious only when something goes wrong) C=Bureaucratic (systems in place to manage safety) D=Proactive (always on the alert about patient safety_ E= safety is integral to all that we do What are the most frequently identified root causes of sentinel events in 2012? - ✔ANS: human factors What does root cause analysis do? (RCA) - ✔ANS: -finds fundamental causes that, if corrected, will prevent reoccurrence of adverse event

-identifies the basic and causal factors that underlie variation in performance -focuses on improving the system rather than hammering the individuals What are the 10 elements of the taxonomy of individual failure modes? - ✔ANS: competency, consciousness, communication, critical thinking, compliance, structure, culture, process, policy, and tech/environment what are the 3 steps to individual and system failure modes and corrective action - ✔ANS: 1)determine failure mode subcategory 2)develop corrective actions 3)list action items ** Rank order of error prevention strategies from lowest to highest (this is on exam) - ✔ANS: suggestions to be more vigilant, education and information, policy/roles, reminders and checklists, redudancies, standardization, forcing functions, fail safes and constraints. What is PDSA cycle? - ✔ANS: -rapid cycle tests to determine which interventions work and repeating rapid cycles. -plan, do , study, act. what is the Plan portion of the cycle? - ✔ANS: -define the objective, questions, and predictions. plan to answer the questions what is the do portion of the cycle? - ✔ANS: carry out the plan, collect data, and begin analysis of the data what is the study portion of the cycle? - ✔ANS: complete the analysis of the data, compare the data to predictions, summarize what we learned

what is the act portion of the cycle? - ✔ANS: plan the next cycle, decide whether that change can be implemented.