Lecture 25+26+DLA Flashcards
(44 cards)
potential ADE
an error that is intercepted before reaching the patient
preventable ADE
an error that reaches the patient and causes some degree of harm
non-preventable ADE
an adverse outcome though medications are prescribed and administered appropriately
the causes of medication errors
- patient specific causes
EX: elderly taking multiple medications are more vulnerable to ADE - drug specific causes
EX: look alike or sound alike meds - clinician specific causes:
unnecessary drug prescription, transcribing errors, dosage errors, failure to identify a drug allergy
how to to reduce medication errors?
transcription training
using the 5R’s
(right drug, right patient, right does, right route, right time)
CPOE (computerized physician order entry)
how to reduce hospital-acquired infections
- hand washing- single most affective method
more sinks
more alcohol based hand rubs
no artificial nails
changing gloves
risk factors for patient falls
- over the age of 60
- taking multiple drugs (sedatives, hypnotics, antidepressants)
- impaired memory
- difficulty walking
how to reduce patient falls
- identify high risk people
- education
- safety rounds
- bed alarms
- safety companions
no-fault errors
Result from factors outside the control of the clinician or the health care system
Ex: atypical disease presentation
patient providing misleading info; uncooperative
systems-related error
The result of technical or organizational flaws
EX: inadequate communication and care coordination inefficient processes technical failure equipment issues
cognitive errors
diagnoses that are wrong, missed, or unintentionally delayed due to clinician error
Anchoring bias
A wrong diagnosis made when clinician maintains initial
impressions when making a diagnosis, and becomes
dismissive to signs and symptoms that points to another diagnosis
confirmation bias
Looking for evidence and interpretation of information to fit a preconceived diagnosis rather than the converse
Availability bias
More recent and readily available answers and solutions are preferentially favored because of ease of recall and incorrectly perceived importance
most cognitively available diagnosis
Diagnosis Momentum
When the diagnosis considered by one clinician becomes the definitive diagnosis as it passed from one clinician to the next; it then becomes accepted without
question by clinicians down the line
framing effect
Diagnostic decision-making unduly biased by extraneous and collateral information
slips (medical error)
Actions not carried out as intended or planned
Ex: giving an iv injection instead of subcutaneous
lapses (medical error)
missed actions and omissions
ex: forgetting to monitor a patient and replacing serum K in a patient with AHF
Mistakes (medical error)
A wrong intended action
e.g., a faulty plan or incorrect intention
violation
not a type of medical error
Deliberate actions whereby someone does something and knows it to be against the
rules
EX: deliberately failing to follow proper procedures
near-miss (outcome of medical error)
Errors that occur but do not result in injury or harm to patients because they are caught in time or simply because of luck
adverse events (outcomes of medical errors)
Harm or injury that results directly from the management of a patients’ disease or condition by health care professionals rather than by the underlying disease or condition itself
Sentinel event (outcome of medical error)
Adverse event in which death, permanent or severe temporary harm to a patient has occurred; used to refer to events that were not at all expected or acceptable
Never Event / Serious Reportable Events (outcome of medical error)
adverse events in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility
Ex: surgical events product events care management events potential crime event
