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Flashcards in Chapter 3 Deck (14):

Adverse event

an injury caused by medical management rather than by the underlying disease or condition of the patient; some but not all adverse events are the result of medical error
Most common: medication


Medical error

the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim


Treatment-related errors

those that occur in performance of an operation, procedure, or test; in administering treatment; or in the dose or method of using a drug; can be the result of an avoidable delay in in treatment or in responding to an abnormal test result or inappropriate care


Preventive errors

failure to provide prophylactic treatment or inadequate monitoring or follow-up of treatment


Near miss

an event or situation that did not produce patient injury but only by chance


Causes of medical errors

i. Communication problems
ii. Inadequate information flow
iii. Human-related problems
iv. Patient-related issues
v. Organizational transfer of knowledge
vi. Staffing patterns and workflow
vii. Technical failures
viii. Inadequate policies and procedures


Swiss cheese model

any one failure or situation alone would be insufficient to cause an accident, but the combination and timing of small failures look like the alignment if holes in a piece of Swiss cheese that has been sliced


Active vs. latent failures

Active - occur at the level of the frontline practitioner
Latent - weaknesses in the organization whose effects are usually delayed
Ex- active failure is nurse administering wrong dose of chemo; latent failure is budget cut that led to nursing shortage


Blunt End/Sharp End Model

Assumes that health care workers at the sharp end, where patient care is delivered, are affected by decisions, policies, and regulations made at the blunt end, or hospital administration side, of the system


Hindsight bias

Occurs when the investigators work backward from their knowledge of the outcome of the event; makes the path to failure look as though it should have been foreseeable, although this is not the case (instead do root cause analysis)


Organizational culture

Organizational culture is the set of values, guiding beliefs, or ways of thinking that are shared among members of an organization


Culture of safety

A culture emphasizing blameless reporting, successful systems, knowledge, respect, confidentiality, and trust. As opposed to asking “who did it?” a culture of safety asks “what happened?” and looks at the system, the environment, the knowledge, the workflow, the tools, and other stressors that influence provider behavior


Just culture

Means that having a safety culture doesn’t mean there is no role for punishment; punishment is indicated for willful misconduct, reckless behavior, and unjustified, deliberate violation of rules, but not for human error.


Reciprocal accountability (stop the line)

Everyone holds everyone accountable for patient safety (stop the line)