Chapter 14: Basic Science of Patient Safety Flashcards
What are the 5 R’s to help reduce or prevent medication errors?
- right drug
- right patient
- right dose
- right route
- right time
What is the pneumonic to help remember how to assess the fitness of a health care professional?
I: Illness
M: medications
S: stress
A: alcohol
F: fatigue
E: eating
Availability bias.
tendency to assume a diagnosis based on recent patient encounters or memorable cases
What is RCA and is it prospective or retrospective?
root cause analysis
retrospective
What is the name of an analysis tool which takes a prospective approach to engineering a method which seeks to anticipate and prevent adverse events through safety design?
FMEA (failure mode effects analysis)
What are the 6 aims of healthcare? (Principles of Quality Improvement)
STEEEP
- safe
- timely
- effective
- efficient
- equitable
- patient-centered
What are balancing measures?
ask whether changes made to improve one part of the system causes an unanticipated decrease in performance in another part of the system
What does PDSA stand for?
plan, do, study, act
What is the aim of the six sigma system?
uses specific steps to reduce variation and improve performance
It is an improvement system for existing processes falling below specification
What does DMAIC in the six sigma system stand for?
Define: define problem in detail
Measure: measure defects ( in terms of “defects per million” or sigma level)
Analyze: do in-depth analysis using process measures, flow charts and defect analysis to determine the conditions under which defects occur
Improve: define and test changes aimed at reducing defects
Control: what steps will you take to maintain performance?
Lean system of improvement.
improvement process that seeks to improve value from the patient’s perspective by reducing waste in time and resources that do not enhance patient outcomes
What are pareto charts?
charts used to describe a large proportion of quality problems being caused by a number of causes; based off of the idea that a number of safety errors stem from only a few recurring contributing factors
Convenience sample
a study group or population used in the test of a quality improvement initiative
Goals should be SMART means what?
Specific
Measurable
Achievable
Realistic,
Time Sensitive
Adverse event.
any injury caused by a medical event
Authority gradient.
command hierarchy of power or balance of power measure in terms of steepness
Closed loop communication.
a type of communication whereby, when a request is made of team members, someone specifically affirms out loud that he will complete the task and states out loud when the task has been completed
Error
failure of planned action to be completed as intended
Forcing function.
aspect of a design which prevents a specific action from being performed or allows its performance only if another specific action is performed first
Medication reconciliation?
process of avoiding unintended inconsistencies in medication regimens which can occur with any transition in care
Near miss (or close call)
an error or other incident which does not produce patient injury, but only because of intervening factors or pure chance
Compare and contrast QA with QI?
QA an older term not likely to be used today, was reactive, retrospective, policing
QI involves both prospective and retrospective reviews; aimed at improvment measruing where you are and figuring out ways to make things better
SBAR
a form of communication first developed for use in naval military procedures
S situation (what is going on with the patient?)
B background ( what is the clinical backgroud or context?)
A assessment (what do I think the problem is?)
R recommendation/request (what would I do to correct it?)
Sentinel event
adverse event in which death or serious harm to a patient has occured; used to refer primarily to events that were not at all expected or acceptable
