Medical Errors Flashcards

1
Q

What are the costs of medical errors and give examples

A
  1. Financial: extended hospital stay, more testing etc
  2. Psychological: they are trusting you to take care of them
  3. Physical: discomfort, disability, death
  4. Staffing: short staffed/physicians can be put on probation causing short staff
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2
Q

Definition of medical error

A
  1. An event that may cause harm to a patient
  2. An unintended injury caused by medical management that results in measurable disability
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3
Q

Causes of medical errors

A
  • Schedule instability: limited practitioners causes other to have to do overtime
  • Sleep deprivation
  • Provider burnout: overloaded/productivity
  • Workload
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4
Q

Types of errors and define

A
  • omission: result of actions not taken when they should have
  • commission: result of wrong action taken
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5
Q

Name some common medical errors

A

Adverse drug reactions
Catheter associated UTI
Central line infection
Pressure ulcer
Obstetric events
misdiagnosis
Venous thrombosis
Ventilator associated pneumonia
Falls
Equipment failure
Burns
Preventable suicide

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6
Q

Active error

A

The actual event that results in harm
- associated with 1st person of contact

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7
Q

adverse error

A
  • an error/injury that most frequently is due to medical/surgical treatment
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8
Q

latent error

A

systems/processes design that results in an error

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9
Q

Medical error

A

Medical error: failure to do the right thing/do something knowing it could be contraindicated

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10
Q

negligence

A

Negligence: Failure to act in accordance with the standard of medical care

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11
Q

negligent adverse effects

A

Negligent adverse effects: an injury occurring during the course of medical management

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12
Q

near miss:

A

Near miss: an event that could have resulted in harm done to the patient but did not cause injury

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13
Q

Never event

A

Never event: an event that caused harm that never should have happened

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14
Q

noxious episode:

A

Noxious episode: an expected reaction to an intervention that may be uncomfortable, painful or upsetting

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15
Q

For basic Patient safety one should always

A

check devices and environment

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16
Q

potentially compensable event

A

Potentially compensable event: where there would be compensation for the event/malpractice claim

17
Q

root cause

A

Root cause: Something that if corrected would eliminate the event from occurring

18
Q

sentinel event

A

Sentinel event: a patient safety event that results in death, permanent harm, or severe temporary harm

19
Q

How to create a safer environment? (joint commission)

A

joint commission has identified patient safety goals to assist facilities
ex:
- identifying patient safety dangers and risks
- confirm ID with 2 sounces
- preventing surgical mistakes
- eliminate blame/own mistakes - culture of education and prevention
- better screening and monitoring

20
Q

3 general sources of health technology induced errors

A
  • design and development
  • implementation and customization
  • interactions between the operation of a new technology and the new work processes
21
Q

Possible causes of technology induced errors

A
  • human factors
  • sociotechnical
  • organization
  • software factors
22
Q

Prevention of technology induced errors

A
  • software design, development, implementation, monitoring ad maintenance
23
Q

What can we as a PT do to reduce medical errors

A
  • fill in gaps in your knowledge
  • thorough screening and evaluation
  • understand signficicance and relevance of PMH, medications lab results
  • thorough and accurate documentation on patients
    communicate clearly with patients, families, caregivers, other health care providers
  • be aware of safety concerns and environment
  • monitor patient response to treatment
24
Q

Root cause analysis

A

a process for identifying the causal factors underlying variations in performance