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Medical Errors

Terms in this set (20)

What is the top contributing factor to medical errors?
communication
TJC says half of the incidents occurred where?
at transfer- Hand-offs -
Hand-off communications must be?
standardized and receiver must be able to ask questions.
TJC requires self-reporting of what?
medical errors and root cause analyses
hoe often do the National Patient Safety Goals (Started in 2003) change?
change every year based on review of sentinel events.
What is the universal protocol?
Preventing wrong site, wrong procedure, and wrong surgery----preoperative verification, mark the site, time-out before starting
What is Sentinel Events Data Collection ?
unexpected occurrences involving death or risk of serious physical or psychologic injuries
What are the OR sentinel events that may occur?
1. anesthesia incidents
2. medical equipment injuries
3. medication errors
4. infections, fires, transfusion errors
5. operative or postoperative errors
6. retained surgical items (RSI) / retained foreign objects (RFO)
7. wrong site/patient/procedure
What are the five checks for medication?
-right patient
-right time
-right dose
-right medication
-right route
how is medication administration done in the OR?
-Containers should always be marked with medication and dose

-Verify verbally when passed to surgeon
Centers for Medicare & Medicaid Services (CMS) refuses to pay for what?
extra cost of treatment to correct those errors
What are examples of extra errors that the CMS will not pay for?
Pressure ulcers, falls and trauma, surgical site infections, vascular catheter-associated infections, catheter-associated urinary tract infections (CAUTI), incompatible blood transfusions, air embolism, RFO, wrong patient/procedure/site, DVT, pulmonary emboli, readmission within 30 days
Agency for Healthcare Research and Quality (AHRQ)
does what?
-Focus on safety/quality, effectiveness, and efficiency
-Clinical practice guidelines
American National Standards Institute does what?
Provide standards about exposures to toxic materials and safe use of equipment (lasers)
U.S. Food and Drug Administration (FDA) does what?
Regulate implantable devices, drugs
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