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Leadership Final

Terms in this set (115)

what article came out in 1999 that revealed how many medical errors were occurring in hospitals
To Err is Human: Building a Safer HealthCare System
****** Global Trigger tool********
a standardized documentation form that looks at adverse events/incidents that can be related to medical error/iatrogenesis
-tool for measuring adverts events
3d most common cause of death is
medical error
**** things that can causeiatrogenesis/iatrogenic events*****
-diagnostic or therapeutic procedures
- relating to illness caused by medical examination/treatment
-side effects of drugs
-adverse drug interactions/reactions
-medical error/negligence
is global trigger tool validated and recommended
yes
who validated and recommended the global trigger tool
IHI
***iatrogenesis is*****
medical harm
strategies to reduce death with medical error
-making errors visible when made
-remedies to rescue patients (rapid response teams)
- follow principles that take human limitation into account
-routinely discuss prevention strategies and disseminate lessons
ENCOURAGE MEDICAL ERRORS TO BE REPORTED FOR DATA SO WE CAN FIGURE OUT HOW TO FIX IT
...
things leader should do to improve safety
-walk rounds
-brief and debrief with teams
-schedule presentations for safety
-discuss best practices
-engage with physicians, patients, and caregivers
in order to reach a safer environment leader must identify what
aims
PDSA stands for
Plan
Do
Study
Act
things global trigger tool may be used for
-positive blood cultures
-readmission within 30 days
- restraint use
- mechanical ventilation greater than 24 hours
- intra-op epi and norepi
- glucose <50
***"Learn global" means to
look for best practices beyond borders of our country
*****"Act local" means to
recognize our performance gap and bring awareness to action
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