Chapter 3 Flashcards
(14 cards)
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)
