Certified Professional in Patient Safety study guide

Certified Professional in Patient Safety
study guide
iatrogenesis - Greek for originating from a physician
preventable adverse events - those that occurred due to error or failure to apply an
accepted strategy for prevention
Ameliorable adverse event - events that, while not preventable, could have been less
harmful if care had been different
adverse events due to negligence - those that occurred due to care that falls below the
standards expected of clinicians in the community
near miss - an unsafe situation that is indistinguishable from a preventable adverse
event except for the outcome - exposed but does not experience harm either through
luck or early detection
error - broader term referring to any act of commission or omission that exposes
patients to a potentially hazardous situation
adverse event - An injury caused by medical management (rather than the underlying
disease) and that prolonged the hospitalization, produced at disability at the time of
discharge, or both
commision - doing something wrong
omission - failing to do the right thing
CPOE - Computerized Provider Order Entry
2009 HITECH Act and meaningful use program
computer alerts three main findings - 1. modestly effective at best
2. alert fatigue is common
3. fatigue increases with exposure and heavier use of CPOE systems
minimize alert fatigue - 1. increase alert specificity to reduce inconsequential alerts
2. tier alerts according to severity
3. make only high level/severe alerts interruptive
4. use human factors principles
three concepts that influence safety in ambulatory care - 1. role of pt and caregiver
behaviors
2. role of provider-pt interactions
3. role of community and health system
Medical Office Survey on Pt Safety Culture - designed to assess safety culture in amb
care and data is available from AHRQ
Pt Engagement - 1. ed pt about their illness and medications with pt demonstrating
understanding "teach back"
2. empowering to act as a safety double check
checklist - Algorithmic listing of actions to be performed for a given clinical procedure
designed to ensure that no matter how often performed by a given clinician, no step will
be forgotten
reduce risk of slips
consensus of required behaviors
slips - failure of schematic (autopilot) behaviors
lapses in concentration, distractions, or fatigue
mistake - failures in attentional behavior
lack of experience or insufficient training
Situational Awareness - the ability to access and track relevant to the task,
comprehend the data,
forecast what may happened based on the data, and
formulate an appropriate plan in response
situational awareness cannot be achieved without - clear and high-quality
communication between all providers
most common root cause of sentinel events - communication
elements the affect communication - 1. rigid hierarchies
2. overtly disruptive and unprofessional behavior
3. nonverbal cues
4. interpersonal relations
5. group dynamics
communication tools - read-back protocols
SBAR
teamwork training
process for prescribing and adm meds - 1. order
2. Transcribing
3. dispensing
4. administration
90% errors occur at ordering (48%) or transcribing thus CPOE prevent
CDSS - Clinical Decision Support System
assist healthcare providers in the actual diagnosis and treatment of patients, analyze
data from clinical information systems
avoids commission and omission errors
unintended consequences of CPOE - 1. more or new work for clinicians
2. unfavorable workflow
3. never-ending system demands
4. persistence of paper orders
5. changes in communication patterns and practices
6. neg towards new technology
7. new types of errors
8. change in power structure, org culture , or professional roles