CPHRM Clinical/Patient Safety 2014
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| Obstetrics risks | failure to identify nonreassuring fetal status; failure to complete C/S; Oxytocin admin; VBAC
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| ED risks | medical eval and transfers; communication issues; ostensible agency
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| Surgical risk | retained items; misidentification of the patient or site; inadequate preop eval; outpatient surgery
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| Anesthesia risks | failure to properly intubate; conscious sedation; patient care responsibilities
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| ICU risks | med admin; use of monitoring alarms; medical management with multiple providers
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| Peds risks | appropriate services and equipment; child abuse; patient safety; abduction
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| Behavioral Health risk | failure to prevent suicide; outpatient ; restraints; psychopharmacology polypharmacy; electroconvulsive therapy; elopement; sexual assault; rights of others
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| Radiology risks | management and avoidance of contrast media reactions or tissue damage from extravasation
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| Home health risks | supervision; durable medical equipment; confidentiality of MR; security
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| Physician Office setting risks | training; timeliness of appointments; patient tracking and diagnostic follow-up
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| Long Term Care and Assisted Care risks | patient’s rights; staffing; abuse; slips/falls; pressure ulcers; elopement; restraints; documentation
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| PCMH | Patient Centered Medical Home
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| ACO | accountable care organization
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| 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.)
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| 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
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| 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
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| 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)
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| HRO | High Reliability Organizations; organizations that operate complex systems without mistakes over long periods of time
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| HRO considerations | sensitivity to operations; preoccupation with failure; deference to expertise; resilience; reluctance to simplify
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| 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
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| Heuristics | mental shortcuts or cognitive bias
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| Cognitive Bias categories | availability heuristic; anchoring heuristic; framing effects; blind obedience
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| Availability heuristics | diagnosis made based on past experiences (e.g., patient incorrectly treated for GI upset despite presence of cardiac symptoms)
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| 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)
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| Framing effects | diagnosis unduly influenced by or prejudiced by collateral information (e.g., known drug addict diagnosed with overdose rather than stroke)
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| Blind obedience | diagnosis made from undue reliance on lab results (e.g., false positive pregnancy test resulted in missed appendicitis)
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| Cognitive slips | tend to occur in situations that are so routine that they have become rote
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| Cognitive lapses | generally not visible because reflective of a memory failure
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| 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
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| Swiss Cheese Model | model used in risk analysis likening human systems to multiple slices of swiss cheese, stacked side by side
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| 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
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| Contributing factors | team; individual staff; task; patient; work environment; organization and management; institutional context
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| Patient safety influencers | public reporting; value based purchasing; healthcare reform and reimbursement; business intelligence; ROI (return on investment) business case
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| PSI | Patient Safety Indicators
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| HACs | CMS’s Hospital Acquired Conditions
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| POA | present on admission
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| 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
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| 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
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| Typical time taken to do an RCA | minimum of 3 one hour meetings
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| RPN | FMECA Risk Priority Number: occurrence x detection x severity
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| Authority gradient | hierarchical
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| 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
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| 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)
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