Final Flashcards
what areas can harm effect
physical, emotional, social, spiritual
Harmful incident
results in harm to a patient
Near miss
a safety incident that did not reach the patient and therefore no harm resulted
No harm incident
A patient safety incident that reached the patient but did no cause harm
A system grounded on safety does what?
Recognizes risks and acts on them
Adverse event
unexpected and undesired effect during the process of providing care
Contributing factor
the reasons, situations, factors or latent conditions that cause an adverse event
Critical incident
A serious incident resulting in the loss of life or a body part
Disclosure
A caregivers well-defined communication process to inform the patient and their families of a safety issue
Incident
An event, process, or outcome that creates a risk for patients
Patient safety
A practice designed to promote positive patient outcomes by reducing and intercepting harmful acts
Root cause analysis
A systematic process of investigating a critical incident to determine the multiple, underlying, and casual factors
Risk
probability of danger, loss, or life-threatening injury within healthcare
Risk management
an organizational strategy designed to reduce and prevent adverse events or moderate the actual financial losses following undesired outcomes
System failure
describes the entirety of health care process, operation, or structure that causes the patient or health care workers injury or undesired outcome
Swiss cheese model
(James reason), Holes are the holes in the safeguard, Harmful events can pass through each layer of the system. It takes multiple failures to lead to a patients harm. A fault, breakdown, or dysfunction
Domino theory
(WH Heinrich), Safety events take form in falling dominos. Each time it passes through a system a domino falls causing the next to fall and the domino begins and is not stopped.
Iceberg model
(Mr Smith), Above the water are the easy things to see for example wrong sling to emergency stop not working, Just under water line is things that are uncovered with deeper investigation that are indirect like no policy, poor mechanical lift, the deeper it goes is the the root analysis like unit short staffed, budget cut
Quality improvement
A range of strategies and techniques that are designed to improve patient safety and quality across systems
4 approaches to quality improvement
- Scientific approach and evidence based
- Emphasis on system not individual people
- A team work
- Continuous
Root cause analysis Process
Gather info, initial understanding, additional information, literature review, timeline and final understanding, determine contributing factors and root causes, formulate casual statements, develop actions
Disclosure
-How incident was handled, future plans to minimize the event of occurring again, regret the event occurred
Canadian Interprofessional health collaborative framework competencies
Role clarification, team functioning, patient/family/community centred care, collaborative leadership, and inter interprofessional conflict resolution
Role clarification
Knowing your own role and the role of others, communicate roles, knowledge and skills, access others skills