Patient safety

Question 1

Within the healthcare industry, what causes the most adverse events?

Answer 1

Drug related injuries cause the most no. of adverse events.

Question 2

NCCMERP medication error categories:

There are 9 categories of medication error:

Category A to I.

Can you list them all?

Answer 2

Cat A:
Circumstances or events that cause the error (e.g leaking air con)

Cat B:
An error occurred but did not reach the pt

Cat C:
An error occurred that reach the pt but caused not harm

Cat D:
An error that reached the pt and require monitoring to confirm no harm

Cat E:
An error that led to temporary harm to the pt

Cat F:
An error that led to temporary harm to the pt & require hospitalization

Cat G:
An error that led to permanent harm in pt

Cat H:
An error that requires intervention to sustain pt life

Cat I:
An error that led to pt’s death

Question 3

What does IASE stand for in pt drug monitoring?

Answer 3

I - Indication
A - Adherence
S - Safety
E- Efficacy

Question 4

What is Patient Safety?
(There are 5 statements that makes up pt safety)

Answer 4

1. Freedom from unnecessary harm or potential harm associated w healthcare
2. Freedom from accidental injuries during cause of medical care
3. Actions undertaken by individuals & organisation to protect pts from being harmed by effects of healthcare services
4. Reduction & mitigation of unsafe acts
5. Use of best practices shown to lead to optimal pt outcomes.

Question 5

Explain the Swiss Cheese Model.

Answer 5

According to this metaphor, in a complex system, hazards are prevented from causing human losses by a series of barriers.

Each barrier has unintended weaknesses, or holes – hence the similarity with Swiss cheese.

These weaknesses are inconstant – i.e., the holes open and close at random. When by chance all holes are aligned, the hazard reaches the patient and causes harm.

This model draws attention to the health care system, as opposed to the individual, and to randomness, as opposed to deliberate action, in the occurrence of medical errors.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1298298/#:~:text=According%20to%20this%20metaphor%2C%20in,open%20and%20close%20at%20random.

Question 6

What is the objective of HFAC framework?

HFAC - Human Factors Analysis & Classification System

Answer 6

To identify both active & latent failures that led to an adverse event.

Provides comprehensive analysis at all levels.

Avoids blaming culture.

Question 7

What are the strongest ways to achieve patient safety?

Answer 7

1. Use more machines designed for the specific purpose
2. Standardise equipment or processes
3. Simplify processes
4. Conduct architectural changes

Question 8

What is the PDSA framework?
(This framework is to analyse effectiveness of new ideas)

Answer 8

P - Plan
D - Do
S - Study
A - Act

Plan the action. Do the action. Study the results. Act on what can be improved.

Question 9

What does the Culture of Safety tell us?

Answer 9

Everyone’s safety is interlinked.

The patient’s safety, the staff’s safety and the student’s safety all all linked.