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Lecture 30: Patient Safety II- Systems Based Practice for Quality Improvement

Terms in this set (47)

Healthcare is an Inherently complex system
Simple Truths about Medical Errors
Doctors make mistakes...Can we talk about that?
Practice Q1
Ans: D
Patient Safety is the process of ...... , ...... and ..... of injuries or outcomes that arise as a result of healthcare process?
Amelioration, Avoidance and Prevention
The Objective of Error reporting is to mitigate .....? If Error-prone situations are reported and managed by ........ of the system, a decrease in frequency of the error and concomitant errors associated with it will occur?
Future errors

Modification (redesign)

DO NOT focus on identifying who is responsible for with a view to take punitive action. It is estimated that only 5% of patient harm is due directly to incompetence or poor intentions
Medical errors that need to be reported are ...... errors, .... events and ..... events?
Near-miss

Adverse

Sentinel
...... errors do not need to be disclosed to patients or families; however, should be reported to the system's administration so that the error to be studied in an attempt to learn how to prevent it in the future?
Near miss
..... and ..... events need to be disclosed the Patient, as well as the Patient's Family and in addition reported to the Hospital?
Adverse and Sentinel
The Gold Standard for disclosing Medical errors involves- giving Accurate description of the events and their ..... on the patient, sincere ..... showing care and compassion and ...... that steps are being taken to prevent the event from happening in the future?
Impact

Apology

Care
Components of a Safety Culture
...... model of Failure/Accident causation illustrates that, although many layers of defense lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident to occur?
Reason's Swiss cheese
Reason's Swiss cheese model consists of .... factors, ..... factors, .... failures and .....?
Latent factors

Error-producing factors

Active failures

Defenses
In Reason's Swiss cheese model- ...... Factors are Errors taking place between a person and an aspect of a larger system at the point of contact ie it's an accident happening? Examples of this include ..... and ......?
Active Factors

Slips and Mistakes

•E.g. wrong IV pump dose
programmed
In Reason's Swiss cheese model- ....... factors are Errors in a system or process design; present but may go unnoticed for a long time with no ill effect ie are accidents waiting to happen?
Latent Factors

eg: Faulty equipment, lack of staff training, ineffective organizational structure

•E.g., faulty IV pump used
The Swiss Cheese Model of Accident Causation contains Successive layers of ..... , ....... and ......?
Defenses, Barriers and Safeguards
Swiss Cheese Model of Accident Causation- Case
Swiss Cheese Model Defenses : Defense-in-depth
-To make sure this does not happen in the future we need to introduce some defenses/ barriers

-Eg: change in policies, training, automation introduction,
In the Swiss Cheese Model of Accident Causation- the goal of Systems-thinking analysis is to Redesign system not necessarily to remove the possibility of error but rather to create/reinforce ..... to reduce harm?
Barriers
An example of a Barrier to reduce harm Swiss Cheese Model of Accident Causation is implementation of a ..... which based on a patient's electronic health record can for eg alert a prescriber and pharmacist to the allergy that the patient might have?
CPOE (Computer Physician Order Entry)

- Even if the prescriber somehow ignores the CPOE alert, implement additional system in pharmacy to serve as a back-up to prevent the medication error.
Swiss Cheese Model Defenses for Pandemic Virus
Practice Q2
Ans: B

- intended to do something but did something else --> Slip
One of the Main methods for Analyzing Medical Errors is .........?- is used to identify the causative factors that underlie variations in performance?
Root Cause Analysis (RCA)
Root Cause Analysis (RCA) typically evaluates ..... events that result in Physical or psychological injury or death, it Identifies the cause and improves the ..... and ...... to decrease the odds of a repeat event and it Generally serves as input to a ..... process?
Sentinel

Systems and Processes

Remediation
Sentinel Events- The Joint Commission
- When joint commission receives RCA they put them together and then puts a recommendation --> Sentinel event alerts

- Helps implement systems approach to help avoiding errors
Root Cause Analysis (RCA) is a ..... approach applied after failure event with the goal to prevent its reoccurrence? The Key purpose of RCA is to answer .... , .....and ..... did this happen? not "Whose fault is this?"
Retrospective

What, Why and How

- Uses records and participant interviews to identify all the underlying problems that led to an error.
The Key steps during a Root Cause Analysis (RCA) are: 1- ..... and ...... the problem clearly, 2- Establish a ..... from the normal situation up to the time
the problem occurred, 3- Distinguish between the ..... and other ..... factors and 4- Establish a ..... graph between the root cause and the problem?
Identify and Describe

Timeline

Root Cause and Causal factors

Causal
The ...... aka .... diagram is a Cause-and-Effect diagram used in Root Cause Analysis (RCA)?
Fishbone aka Ishikawa

- You first ID the problem, then draw the spine- then ID the primary causes leading to that problem, then ID secondary causes that exaggerate primary causes
Case Review
1 --> RCA Analysis

2 --> Fishbone diagram
Case Review- Fishbone diagram
-Problem --> Maternal death

-Then ID the primary reasons that can lead to maternal death

-All of the conditions are summed up and lead to maternal death

-Objective is to find ways to improve/deal with these problems
Another method used to analyze errors besides RCA is the ...... approach?- this is a ..... and ..... process of anticipating failures, determining the impact of those failures and determining the likelihood of that failure being detected before it occurs?
FMEA (Failure Mode and Effect Analysis)

Systematic and Proactive

ie given a particular situation and then you think ahead about what errors can occur in this setting
The Goal of FMEA (Failure Mode and Effect Analysis) is to Prevent patient problems ..... they occur?
Before

Assumptions
1- FMEA concludes errors will occur even if healthcare professionals are careful

2- FMEA engages in a continual process of quality improvement to assess and
correct areas where an error has occurred or is likely to occur
..... is the a rating used in FMEA to indicate the combined probability, severity, and undetectability of a failure mode? Formula?
Risk Priority Number (RPN)

RPN= Severity of Effect x Probability of Occurrence x Probability of Detection
Failure Mode & Effects Analysis Process Map
FMEA- RPN Example
-You create your own scale
-Highest number of that scale is most extreme eg: 10 is severe outcome
Human Factors in Design
The Plan-Do-Study-Act (PDSA) Cycle is a Four-step cycle that allows one to ..... implement relatively ......-scale change, solve problems and ..... improve processes?
Quickly

Small

Continuously
The 4 Steps involved in a Plan-Do-Study-Act (PDSA) Cycle are: 1- ..... , 2- ...... , 3- ...... and 4- ......?
1- Plan

- Define problem and plan a solution

2- Do

- test new process

3- Study

- Measure and analyze data

4- Act

- integrate new process into regular workflow
PDSA Example-1
-We notice patient wait time in ER is increasing so we think of what we can do to reduce wait time

-Then boss will tell us to do a PDSA

-We can choose all of them so we will choose 1 ie --> who calls cleaning crew
PDSA Example-2
-We make small improvements

-Continuously make small changes that can eventually lead to large systems improvement
Integrated Example-1
-Qataris did a retrospective analysis using a Fishbone diagram
-Started with problem- no show rate - then looked at factors that combined that lead to no show rate
-They can fix of all so they chose 1
-They chose patient not interested
Integrated Example-2
Integrated Example-3
Integrated Example-4
The Six Sigma Model (6σ) is a .... driven approach to solve problems requiring .... scale transformation?
Data

Large
Summary
Practice Q3
Ans: C

- retrospective analysis ie RCA uses Fishbone diagram

- A--> prospecitve
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