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CPHRM Clin/Pt Safety

CPHRM Clinical/Patient Safety 2014

Obstetrics risks failure to identify nonreassuring fetal status; failure to complete C/S; Oxytocin admin; VBAC
ED risks medical eval and transfers; communication issues; ostensible agency
Surgical risk retained items; misidentification of the patient or site; inadequate preop eval; outpatient surgery
Anesthesia risks failure to properly intubate; conscious sedation; patient care responsibilities
ICU risks med admin; use of monitoring alarms; medical management with multiple providers
Peds risks appropriate services and equipment; child abuse; patient safety; abduction
Behavioral Health risk failure to prevent suicide; outpatient ; restraints; psychopharmacology polypharmacy; electroconvulsive therapy; elopement; sexual assault; rights of others
Radiology risks management and avoidance of contrast media reactions or tissue damage from extravasation
Home health risks supervision; durable medical equipment; confidentiality of MR; security
Physician Office setting risks training; timeliness of appointments; patient tracking and diagnostic follow-up
Long Term Care and Assisted Care risks patient’s rights; staffing; abuse; slips/falls; pressure ulcers; elopement; restraints; documentation
PCMH Patient Centered Medical Home
ACO accountable care organization
Taxonomy vs. Nomenclature taxonomy: classifying of events (by category, by harm, etc.) vs. nomenclature: words used to describe bad outcomes (sentinel events, unanticipated outcomes, etc.)
Culture of Safety definition an integrated pattern of individual and organizational behaviors, based upon shared beliefs and values, that continuously seeks to minimize patient harm that may result from the processes of care delivery
Culture of safety supports a forum for an unencumbered discussion of events; willingness to go where you don’t know where you’re going to land
Culture of Safety five stages of maturity Pathological (no system); Reactive (piecemeal); Calculative (systematic approach, per event); Proactive (Comprehensive approach across organization); Generative (Meaningful safety culture central to mission)
HRO High Reliability Organizations; organizations that operate complex systems without mistakes over long periods of time
HRO considerations sensitivity to operations; preoccupation with failure; deference to expertise; resilience; reluctance to simplify
Patient safety data deficiencies Confusion about the use of the data; analyzing rare events vs. large segments of data; multiple data streams without a defined process on how to view the data; no central repository for patient safety data; surveillance bias
Heuristics mental shortcuts or cognitive bias
Cognitive Bias categories availability heuristic; anchoring heuristic; framing effects; blind obedience
Availability heuristics diagnosis made based on past experiences (e.g., patient incorrectly treated for GI upset despite presence of cardiac symptoms)
Anchoring heuristic (premature closure) diagnosis made from initial impression although not supported by subsequent data or information (e.g., initial set of cardiac enzymes negative so heart attack ruled out when patient had left arm pain)
Framing effects diagnosis unduly influenced by or prejudiced by collateral information (e.g., known drug addict diagnosed with overdose rather than stroke)
Blind obedience diagnosis made from undue reliance on lab results (e.g., false positive pregnancy test resulted in missed appendicitis)
Cognitive slips tend to occur in situations that are so routine that they have become rote
Cognitive lapses generally not visible because reflective of a memory failure
Cognitive mistakes judgment failures that are more subtle and complex than slips; go undetected for a period of time; left to differences of opinion when detected; can be knowledge based or rule based
Swiss Cheese Model model used in risk analysis likening human systems to multiple slices of swiss cheese, stacked side by side
Sharp vs. Blunt End model The person actually doing the task (e.g., nurse administering meds) is the sharp end of the system whereas the blunt end is the environment in which healthcare is delivered
Contributing factors team; individual staff; task; patient; work environment; organization and management; institutional context
Patient safety influencers public reporting; value based purchasing; healthcare reform and reimbursement; business intelligence; ROI (return on investment) business case
PSI Patient Safety Indicators
HACs CMS’s Hospital Acquired Conditions
POA present on admission
2014 NPSGs Goal 1: accuracy of pt ID; Goal 2: improve communication; Goal 3: Use medications safely; Goal 6: Reduce harm associated with clinical alarms; Goal 7: prevent infections; Goal 15: identify pts at risk for suicide; UP Goal 1: Prevent mistakes in surgery
Sentinel Events requiring RCAs death or major permanent loss; suicide; abduction; discharge to wrong family; rape; hemolytic transfusion reactions involving incompatibility; wrong patient/site surgery; retained objects; hyperbilirubinemia; prolonged fluoroscopy
Typical time taken to do an RCA minimum of 3 one hour meetings
RPN FMECA Risk Priority Number: occurrence x detection x severity
Authority gradient hierarchical
Disclosure definition the delivery of news to the patient or family they may not otherwise learn; not strictly related to medical error, nor necessarily to bad news
Four Rs of Apology Recognition (knowing when and apology is in order); Regret (responding empathetically); Responsibility (owning up to what has happened); Remedy (make it right)
Created by: Camellia Acker Camellia Acker