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Patient safety slides

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The freedom from accidental injury due to medical care or from medical error.Institute of Medicine, 2000
The process through which an organisation makes patient care safer.National patient safety agency, 2003
Percentage of patients suffering injury prolonging their hospital stay.14 % of these were fatal.
Percentage of injuries due to error.Errors are errors of execution, planning or violations.
Percentage of admissions were errors occurNot all errors result in injury.
Incident reporting systems, malpractice claims and complaints, morbidity and mortality conferances, and patient incident reports are examples of this type of measurement.May suffer from bias in reporting, hindsight bias, and is non-standardized.
Case note review, trigger tools and electronic medical record are examples of this type of measurement.Are expensive, and identify only a small portion of errors.
Participant observation and independent observers are examples of this type of measurement.Are expensive, requires well trained observers, are not feasable for rare events, and may suffer from the Hawthorne effect.
The acronym SEIP stands for the ... model.Carayon et al., (2006)
Measuring this type of variable is more cost effective, though evidence is needed for relationship with the outcome, and can produce unexpected results.How care is provided
Authors of the 2014 article 'Psychological contributions to the understanding of adverse events in healthcare'
Executing an action sequence wrongly
Successfully executing a faulty plan
Deviations from rules, protocols or norms, which have an intentional component.Even them, harm is almost always unintentional.
Violation that occurs when skill and experience leads violators to believe the rules don't apply to them.
Type of violation that occurs when the situation neccessitates violation, for example due to time constraints.
Type of violation that occurs when the existing rules cannot deal with a novel situation.
Violation leading to intended harm.
Better system defenses is a remediation strategy for this type of error.
Improved training is a remediatio strategy for this type of error.
Good guidelines, effective implementation and the provision of neccessary resources are remediation strategies for this type of error.
Percentage of anaesthesia errors due to human error.
The tendency to focus on dispositional characteristics when explaining others' behaviour, and situational when explaining our own.Heider (1958)
Bias where the world is viewed as a place where we 'get what we deserve'.
... focused coping strategies include information seeking and problem solving.
... focused coping strategies include venting and denial.Should be used wen dealing with long lasting responses that follows error.
Considering yourself less at risk of a negative event then your peers is an example of...
Bias locating the source of the expected outcome in terms of personal control.
Authors of the 2003 paper 'The measurement of active errors: methodological issues'
... can be broken down into mortality, physichal morbidity, psychological well being, and satisfaction with services.Most mortality and morbidity is not the result of poor quality care.
Errors in patient care itself rather than in the system that may predispose to such errors.Has been argued to be identical to clinical process violations
When quality of care is assessed against predetermined criteria, also called criterion based assessment. Cannot pick up diverse processes.
Assessment based on expert judgement, sometimes referred to as holistic assessment.Poorly standardisised and expencive
Bias where the dilligence with which information is recorded may influence the visibility of errors.
Classification of errors relating to the record of observations (recording oxygen saturation)

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