patient safety 1

Statements such as 'The patient was going to die anyway', 'The patient was a DNR', and 'We don’t know for sure why the patient died' do not impact this determination.

It involves collecting and analyzing information about any event that could have harmed or did harm anyone in the organization.

The SEC is designed to categorize safety events to facilitate analysis and improve patient safety.

It is essential for an organization’s ability to learn from error.

It refers to a state where individuals perform tasks without conscious awareness, often leading to unintentional errors.

It measures the rolling 12-month rate of Serious Safety Events per 10,000 adjusted patient days in hospitals or per 100,000 patient visits in medical groups.

Errors occur due to a combination of active failures and latent conditions that create opportunities for mistakes.

A missed diagnostic error occurs when no diagnosis was made, although information existed to make a correct diagnosis.

People experience slips, lapses, and fumbles when rushing, distracted, multitasking, or fatigued.

It smooths out the rate for infrequent events and encourages sustainability of performance.

It helps in deciding the appropriate response and actions to take following a safety event.

It can reduce error rates by 10 to 100 times.

An incorrect diagnostic error is when a diagnosis was made, but the diagnosis was wrong.

A delayed diagnostic error happens when a correct diagnosis was made, but information existed to make the diagnosis earlier.

Clear communication ensures that information is accurately conveyed and understood, reducing the risk of errors.

A flash fire ensued because the CRNA did not hear the surgeon's request to turn off the oxygen, resulting in severe burns to half of her face.

The 'Read Back' technique involves the receiver repeating the information back to the sender to confirm accuracy.

A Repeat-Back is a communication technique where one party repeats back what another party has said to confirm understanding.

A safety phrase is 'Let me repeat that back…' which helps ensure clarity in communication.

You should ask 1 or 2 clarifying questions to ensure you understand what you are supposed to do.

First, do no harm.

'That’s correct!' is a codeword indicating that both parties understand each other.

The safety phrase is: 'Let me ask a clarifying question...'

The report highlighted the prevalence of medical errors and the need for improved patient safety.

Wrong side surgery.

We need the Be Safe Tools because we are all human and make mistakes, there are poorly designed processes or systems, and individual choices may lead to non-compliance with standards.

The organization did not provide the people, resources, or oversight to support the process or activity being performed.

A symptom, not the cause of failure.

Fatal electrolyte error.

The organization’s values and behavior expectations for leaders, physicians, and staff serve as a counter-influence to safe, reliable individual and team performance.

The cost of doing business in a highly complex healthcare system.

There are deficiencies in the design of the expectations or flow of the work process expectations.

Human error should be the starting point, not the conclusion.

Fatal transfusion reaction.

It emphasizes making harm visible so that it can be addressed and fixed.

There are deficiencies in the documents – policies, procedures, and job aids – that are intended to support the work process and guide individual decision making.

ZERO HARM.

To improve critical thinking by encouraging people to internally question things they hear and see.

Poorly designed processes, unusual situations, failures in education and training, distractions, failures in critical thinking, and individual choices not to comply with standards.

It involves considering what could go wrong and not ignoring risks or small errors.

The organization did not provide the people, resources, or oversight to support the process or activity being performed.

The design of the workplace, equipment, and information systems makes it difficult for the person to carry out the task at hand.

Figure out what you would click next.

The therapist should take the time to validate and verify the order in the chart.

It refers to being aware of what is happening around you in the healthcare environment.

GAPS are standards determined by comparing actual performance to expected performance.

23 deaths annually from medical error.

When results are different than expected, when something 'doesn't feel right' or doesn't make sense, and all the time.

Pilot error and poor training were blamed for the crash, along with the pilots' performance likely being impaired due to fatigue.

It suggests that while making mistakes is human, continuing to make the same mistakes is unacceptable.

The organization’s values and behavior expectations for leaders, physicians, and staff serve as a counter-influence to safe, reliable individual and team performance.

Reporting helps safety and risk leaders to understand and address potential issues daily.

Adam put weight on his knee, which tore much of the surgical repair, requiring additional surgery.

Note the time in seconds when done.

Performance expectations should include internal policies, nationally recognized standards of care, industry-imposed practice mandates, professional practice standards, and the organization's obligation to protect the patient from harm.

There are deficiencies in the design of the expectations or flow of the work process expectations.

To ensure work activities are stopped when faced with uncertainty to minimize the chance of a high-risk situation harming a patient or associate.

Almost one patient every other week.

The captain had not established a good foundation of instrument flying skills, and his weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed.

There are deficiencies in the documents – policies, procedures, and job aids – that are intended to support the work process and guide individual decision making.

Deviations from GAPS are identified by comparing actual performance to expected performance.

Safety coaches should update their team monthly on events reported in their area.

Effective handovers should provide unambiguous transfer of responsibility, promote a shared mental model, occur in protected time and space, minimize interruptions, include up-to-date information, involve family participation, and follow a standardized format.

Embrace transparency.

The design of the workplace, equipment, and information systems makes it difficult for the person to carry out the task at hand.

The NTSB concluded that the pilots' performance was likely impaired because of fatigue.

Patient safety and harm reduction.

Circumcision

It shows how most errors occur due to a combination of failures at the 'blunt' (system) end and common human failures at the 'sharp' end.

To identify recurring problem areas known as 'error traps'.

Skill-Based Performance, Rule-Based Performance, Knowledge-Based Performance.

The procedure was performed on the wrong patient.

By building a culture of safety and using 'be safe' behaviors in daily operations.

10 percent of U.S. deaths are due to preventable medical mistakes.

It refers to Knowledge-Based Performance.

Identifying and removing error traps.

Between 48,000 and 95,000 preventable deaths per year.

HROs strive to make systems ultra-safe to decrease the chance of errors.

The organization did not provide the people, resources, or oversight to support the process or activity being performed.

Brief, Execute and Debrief

Anonymous reporting, timely feedback, open acknowledgment of successes, reporting of near misses.

It signifies Rule-Based Performance.

Forcing functions lead to work-arounds.

The organization did not provide the people, resources, or oversight to support the process or activity being performed.

To point out problems in a positive manner and ensure accuracy before proceeding with high-risk tasks.

Over 400,000 deaths annually.

Redesign so that the error-prone task is no longer necessary.

The organization’s values and behavior expectations for leaders, physicians, and staff serve as a counter-influence to safe, reliable individual and team performance.

Preoccupation with Failure: Consider what could go wrong.

It refers to Skill-Based Performance.

Performed a brief Time Out.

'Free' lessons can be learned from the reporting of near misses.

Situation: The bottom line (diagnosis, current condition, problem).

A chest x-ray revealing diffuse lung nodules.

Stop… Pause for 1 to 2 seconds to focus our attention on the task at hand.

Scanners lead to poor self-checking.

The organization’s values and behavior expectations for leaders, physicians, and staff serve as a counter-influence to safe, reliable individual and team performance.

A Safety Event is any incident that results in harm or has the potential to cause harm. Serious safety events result in significant harm, precursor events indicate potential for harm without actual harm occurring, and near miss events are incidents that could have resulted in harm but did not.

By replacing a manual task with an automated one.

They are considered a reason for errors in the expectations or flow of the work process.

The coffee costs $0.05.

Infection, fall, delayed diagnosis causing delay in treatment, among others.

By providing positive feedback when you catch someone doing it right and discouraging unsafe behaviors.

It emphasizes knowing what’s going on around you.

It suggests that people who make mistakes are poor performers.

System improvements can be instituted at no cost to a patient.

Deference to Expertise

Power of the Pause.

Look Back, Look Ahead, Follow Up.

Sarah's daughter was delivered stillborn after the care team failed to voice their concerns about significant drops in the baby's heart rate.

Background: What do you know? (medical history, past tests or treatments).

They include understanding systems, economics, and laws/policies to provide care that is safe, effective, and efficient.

Lead by example and participate actively.

Alerts lead to alert fatigue.

Think… Consider the action you’re about to take.

The Blunt End refers to where care is designed, highlighting that processes can be flawed.

A CT scan was recommended.

Organizing and prioritizing responsibilities while understanding systems, economics, and laws/policies to provide safe, effective, and efficient care.

There are deficiencies in the design of the expectations or flow of the work process expectations.

The patient safety movement in the US originated in response to increasing awareness of medical errors and their impact on patient outcomes, leading to initiatives aimed at improving healthcare quality and safety.

To determine if the source of information is credible.

Competency refers to the person not having the knowledge or well-developed skill to perform the task.

Transparency is crucial because it fosters trust, encourages reporting of errors, and facilitates the collection, analysis, and sharing of safety data, which is essential for reducing harm.

Ask a question, Make a Request, Voice a Concern, Use your Chain of command.

Deficiencies in the documents – policies, procedures, and job aids – intended to support the work process can lead to errors.

Reluctance to Simplify: Ask questions and avoid assumptions.

Design components so that a mistake is impossible.

Errors can occur due to communicating in a hurry, similar-sounding words, discomfort in asking questions, communication via cell phones, and language proficiency issues.

Significant safety, quality, or service issues from the past 24 hours.

It posits that all people are fallible and that system factors are the majority cause of error.

Assessment: What is happening now? (current findings, needs, concerns).

Sensitivity, honesty, compassion, empathy, making appropriate referrals, delivering bad news, informed consent, and disclosure of medical errors.

Independent checks lead to co-dependency.

By asking encouraging questions of those who are hesitant.

Introduction and Basic Principles of Patient Safety.

The Sharp End represents where care is delivered, indicating that flawed processes can lead good people to make bad mistakes.

Sensitivity, honesty, compassion, empathy, making appropriate referrals, delivering bad news, informed consent, and disclosure of medical errors.

To assess if the information makes sense, aligns with expectations, and fits with past experiences.

Act… Concentrate and carry out the task.

There are deficiencies in the documents – policies, procedures, and job aids – that are intended to support the work process and guide individual decision making.

The results of the CT scan were not communicated to the primary care physician, and no CT was ordered.

The Accident Causation Model, also known as the Swiss Cheese Model, illustrates how errors occur when multiple layers of defense fail, highlighting the importance of both system and individual factors in error causation.

Consciousness implies that the person knows what to do but fails to carry out the task correctly due to distraction.

Stop and address that concern in a respectful manner, regardless of whether the concern is unfounded.

They facilitate by providing reminders and cues.

Types of diagnostic error include missed diagnoses, wrong diagnoses, and delayed diagnoses. Causes can range from cognitive biases to system failures. Clinical scenarios can help identify specific causes and inform strategies for mitigation.

The design of the workplace, equipment, and information systems can make it difficult for the person to carry out the task at hand.

It entails bouncing back from the unexpected.

To anticipate and plan for safety, quality, or service issues that may occur within the next 24 hours.

Recommendation: What is next? (recommendation or request for plan of care).

Communication is not just what you say, but what the other person hears; ensuring accurate understanding is crucial to prevent misunderstandings.

The 'sharp end' and the 'blunt end'.

The AHRQ’s CANDOR processes.

Decision support leads to poor critical thinking.

Disclosing medical errors effectively.

A small group exercise on error reporting.

Thank those that participate.

HROs strive to bridge the gap between the blunt end and sharp end by translating high reliability leadership lessons into actionable items for front line leaders.

The design of the workplace, equipment, and information systems makes it difficult for the person to carry out the task at hand.

Communication errors occur when a person hears information incorrectly or misinterprets its meaning.

To check the information with an independent, expert source.

Review… Check to make sure that the task was done correctly and that you got the correct result.

Pre-operative clearance for foot surgery.

Anyone you work with.

Reporting on issues identified on previous days and what is being done to resolve them.

By adding requirements designed to detect mistakes.

Deference to Expertise: Don’t hesitate to share your expertise.

High Reliability principles focus on creating a culture of safety, continuous learning, and resilience, which collectively lead to significant reductions in errors and enhance patient safety in clinical practice.

The ultrasound report was not available for the patient.

By respecting patient privacy and autonomy, and being accountable to patients, society, and the medical profession while applying relevant laws and policies.

Active failures or unsafe acts, such as slips, lapses, mistakes, and violations, can occur.

To see if either party has any questions.

By respecting patient privacy and autonomy, and being accountable to patients, society, and the medical profession.

Giving report electronically leads to a loss of situational awareness.

If they had voiced their concerns to the physician and escalated the issue, it might have led to a different outcome.

Introduction and Basic Principles, Principles of Improvement Science, Measurement, Metrics, and CQI.

Coach off-line to provide constructive feedback.

The Swiss Cheese Model illustrates how system flaws can lead to errors, emphasizing the need to identify and close 'holes' in safety strategies.

Critical Thinking involves the cognitive processing of information, and failure in this area can lead to poor decision making.

It gives your brain a chance to catch up with what your hands are about to do.

Use the QV&V Technique: Qualify, Validate, and Verify.

Recognizing health disparities and understanding the meaning and role of the Triple Aim in health reform.

Shortages of medical scanners, equipment downtime, and personal health issues like migraines.

Progressive disease in the lungs.

It illustrates that each defense has holes, which can lead to adverse outcomes if penetrated.

The RN contacted Maria’s physician and requested a transvaginal ultrasound to ensure the patient was not harmed.

It relates to recognizing high value population-based care and addressing health disparities.

To perform second checks and double checks.

Concise (5 min), Crisp (agenda-driven), and Consistent (same place).

To catch each other’s errors and mistakes, hold each other accountable for expectations, and benefit from each other’s experience.

Plan-Do-Study-Act, used in applying Continuous Quality Improvement.

Compliance means the person is aware of performance expectations but chooses to act differently.

Consider what problems prevent safe work, what system factors have led to errors, and what 'holes' need to be closed for better safety strategies.

Count the F’s one time and one time only; do not go back and count them again.

Identifying system errors and potential solutions, recognizing that error prevention requires a system approach.

Anna died from acute respiratory distress syndrome after her complaints were assumed to be anxiety.

Stage 4 lung cancer.

Fetal heart tones were identified, leading to the cancellation of the D&C.

Patient or Project, Plan, Purpose of the Plan, Problems, Precautions.

If the whole series of defenses is penetrated, it can lead to a trajectory of 'accident opportunity'.