Patient Safety

Question 1

describe the common causes of unsafe medical care

Answer 1

• medication errors
  
  • 1.5 million deaths occur each year in the US due to medication error
  • common causes
    
    • poor handwriting, dosing or route of administration errors, look-like drugs
• hospital-acquired infxns (HAI)
  
  • 5-15% of all hospitalized patients get an HAI
  • 40% of all ICU patients get an HAI
  • adverse events and injuries due to medical devices
    
    • urinary catheter-related infxns (UTI): 40% of all HAI
  • hospital acquired pneumonia
    
    • 2nd most common nosocomial infxn
  • surgical site infections (SSI)

Question 2

name the structural factors that contribute to unsafe care

Answer 2

• organizational determinants and latent failures
• lack of structural accountability
  
  • use of accreditation and regulations to ensure patient safety
• non-existant safety culture
• lack of training, education of human resources

Question 3

name the human factors that contribute to unsafe care

Answer 3

• communication and teamwork failure
• errors at times of transitions or handoffs
• stress and fatigue
• note: potential for human error amplified by poor working conditions
  
  • production pressure
  • IM SAFE
    
    • illness, medication, stress, alcohol, fatigue, eating
• lack of appropriate knowledge and its transfer
• devices and procedures with no human factors

Question 4

name the process factors that contribute to unsafe care

Answer 4

• misdiagnosis
• poor test follow-up
• counterfeit and substandard drugs
• lack of involvement of patients in patient safety
• no teamwork training

Question 5

name the 3 main types of medical errors

Answer 5

• slips
  
  • actions not carried out as intended or planned
  • e.g. injecting a medication intravenously when you meant to give it subcutaneously
• lapses
  
  • missed actions and omissions
  • e.g. forgetting to monitor and replace serum potassium in a patient treated with furosemide for acute CHF
• mistakes
  
  • a wrong intended action, e.g. a faulty plan or incorrect intention
  • e.g. extubating a patient prematurely based on misapplication of guidelines

Question 6

describe a violation

Answer 6

not a type of medical error

• violations
  
  • deliberate actions whereby someone does something and knows it to be against the laws
  • e.g. deliberately failing to follow proper procedures

Question 7

summarize the types of medical errors

Answer 7

Question 8

describe the different outcomes of errors

Answer 8

• adverse events
  
  • 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
• near-misses
  
  • errors that occur but do not result in injury or harm to patients because they are caught in time or simply because of luck
• sentinel event
  
  • adverse event in which death or serious harm to a patient has occurred: used to refer to events that were not at all expected or acceptable (e.g. an operation on the wrong patient or body part)
• violation
  
  • intentional or deliberate deviation from safe operating procedures, standards, or policies (not an error)

Question 9

describe reporting of sentinel events vs near misses

Answer 9

• sentinel events
  
  • disclosed to patient and family and reported to hospital
• near-misses
  
  • not disclosed to patients or families; however, should be reported to the hospital in order for error to be studied in attempt to learn how to prevent it in the future

Question 10

name the 3 types of diagnostic errors

Answer 10

• no-fault errors
  
  • may happen when there are masked or unusual symptoms of a disease, or when a patient has not fully cooperated in care
• systems-related errors
  
  • technical failure, equipment problems and organizational flaws
• cognitive errors
  
  • diagnoses that are wrong, missed, or unintentionally delayed due to clinician error

Question 11

name the 3 types of common cognitive errors

Answer 11

• anchoring bias
  
  • a wrong diagnosis made when clinician holds on to a particular diagnosis and dismisses other signs and symptoms that point to another diagnosis
• confirmation bias
  
  • looking for evidence to support a pre-conceived opinion rather than looking for evidence that refutes it or provides greater support to an alternative diagnosis
• availability bias
  
  • tendency to assume a diagnosis based on recent patient encounters or memorable cases (i.e. the most cognitively “available” diagnosis)

Question 12

describe the 2 methods of analysis of medical errors

Answer 12

• root cause analysis
  
  • retrospective approach applied after failure event to prevent reoccurrence
• failure mode and effects analysis
  
  • forward-looking approach applied before process implementation to present failure occurrence