Chapter 14: Basic Science of Patient Safety Flashcards

1
Q

What are the 5 R’s to help reduce or prevent medication errors?

A
  • right drug
  • right patient
  • right dose
  • right route
  • right time
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2
Q

What is the pneumonic to help remember how to assess the fitness of a health care professional?

A

I: Illness
M: medications
S: stress
A: alcohol
F: fatigue
E: eating

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3
Q

Availability bias.

A

tendency to assume a diagnosis based on recent patient encounters or memorable cases

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4
Q

What is RCA and is it prospective or retrospective?

A

root cause analysis

retrospective

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5
Q

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?

A

FMEA (failure mode effects analysis)

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6
Q

What are the 6 aims of healthcare? (Principles of Quality Improvement)

A

STEEEP

  1. safe
  2. timely
  3. effective
  4. efficient
  5. equitable
  6. patient-centered
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7
Q

What are balancing measures?

A

ask whether changes made to improve one part of the system causes an unanticipated decrease in performance in another part of the system

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8
Q

What does PDSA stand for?

A

plan, do, study, act

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9
Q

What is the aim of the six sigma system?

A

uses specific steps to reduce variation and improve performance

It is an improvement system for existing processes falling below specification

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10
Q

What does DMAIC in the six sigma system stand for?

A

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?

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11
Q

Lean system of improvement.

A

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

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12
Q

What are pareto charts?

A

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

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13
Q

Convenience sample

A

a study group or population used in the test of a quality improvement initiative

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14
Q

Goals should be SMART means what?

A

Specific
Measurable
Achievable
Realistic,
Time Sensitive

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15
Q

Adverse event.

A

any injury caused by a medical event

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16
Q

Authority gradient.

A

command hierarchy of power or balance of power measure in terms of steepness

17
Q

Closed loop communication.

A

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

18
Q

Error

A

failure of planned action to be completed as intended

19
Q

Forcing function.

A

aspect of a design which prevents a specific action from being performed or allows its performance only if another specific action is performed first

20
Q

Medication reconciliation?

A

process of avoiding unintended inconsistencies in medication regimens which can occur with any transition in care

21
Q

Near miss (or close call)

A

an error or other incident which does not produce patient injury, but only because of intervening factors or pure chance

22
Q

Compare and contrast QA with QI?

A

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

23
Q

SBAR

A

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?)

24
Q

Sentinel event

A

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

25
Wrong site procedure?
operation or procedure done on the wronng part of the body or on the wrong person; can also mean the wrong surgery or procedure performed