To Err is Human (1999)
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Terms in this set (28)
Benchmarking-process of measuring against "best performing organizations" *Internal benchmarking*: using data from within the organization as a comparison (ie. units in same hospital) *External benchmarking*: compares what you are doing against what others are doing (ie. top performers across the country)QI Methodologies*PDSA: Rapid Cycle Test* *Six Sigma*: goal to reduce variation in existing process *DMAIC*: problem-solving steps to reduce variation (define, measure, analyze, improve, and control) *Lean Six Sigma*: reduce variation + eliminate waste8 Common Steps in QI1. Purpose 2. Literature 3. Current Resources 4. Current Processes 5. Root causes 6. Select appropriate tools 7. Select measures and metrics (baseline and outcomes) 8. PDSA (rapid cyclical review)Root Cause AnalysisWhat happened, why, and how to preventCause and Effect/Fish bone diagramhorizontal arrows - issues (ie. floor is wet, no handrails, nurses not rounding) diagonal arrows - potential cause (ie. Equipment, People, Methods)PDCA (plan, do, check, act)/Rapid Cycle Reviewencourages continuous and ongoing efforts to improve outcomes *Plan* - define objective, questions, and predictions *Do* - carry out the plan, collect data *Study* - complete analysis of the data, compare to predictions, summarize knowledge *Act* - plan next cycle, decide whether change can be implementedError-failure of planned action to be completed as intended or the use of the wrong plan to achieve an aim *Latent error* - GREATEST THREAT, dormant problems within the system *Active error* - non-compliant with procedure or making a mistakeMisuseavoidable complications that prevent patients from receiving full potential benefit of a service (ie. patient receives a med not prescribed and conflicts w/ allergies)Overusepotential for harm from the provision of a service that exceeds the possible benefit (ie. Elderly put on multiple meds and multiple healthcare providers do not know meds have been prescribed)Adverse eventinjury resulting from medical intervention, not due to underlying conditionFailure to rescueprevent clinically important deterioration from a complication of an underlying illness or complication of medical care (ie. IV beeps, but no one checks; ventilator alarms)Near-missrecognition that an event occured that might have led to an adverse eventSentinel eventevent that had a negative patient outcome (unexpected death, serious physical/psychological injury, serious risk) ie. pt commits suicide in hospital for treatment of diabetes or depressionHuman factors engineeringhuman element to make product and processes safer to use *unconscious*: forgetting to give a medication, picking up wrong syringe *conscious*: work-aroundsBarriers to error reporting-inability to recognize errors -burdensome documentation -lack of anonymity -hesitancy -unclear reporting requirements for errors w/o adverse outcome -fear of lawsuits -perception that change will not occurCulture of safetyblame-free environment in which staff can practice and openly discuss potential errors or near-misses as well as actual errorsJust Culture"No shame! No blame!" accountabilitySafe Harbor Act-must be done in good faith -protect patients and maintain professional status