Patient Safety
The Swiss Cheese Model of error prevention was developed by this psychologist.
Who is James Reason?
CMS publicly penalizes hospitals with higher-than-expected 30-day readmissions through this program.
What is HRRP (Hospital Readmissions Reduction Program)?
CMS no longer pays for additional costs of care related to certain preventable complications. These are commonly known as this.
What are "never events" (or hospital-acquired conditions)?
This High Reliability principal shifts decision(s) to the person most knowledgeable, not the one with the highest rank.
What is "Deference to Expertise"
This healthcare professional provides bedside care and patient advocacy.
RUSNE
What is a nurse?
This 2001 IOM report followed To Err is Human and emphasized that healthcare should be safe, effective, patient-centered, timely, efficient, and equitable.
What is "Crossing the Quality Chasm"?
This measure set, used in hospital Star Ratings, includes outcomes like mortality, safety, readmissions, patient experience, and timely/effective care.
What are CMS Hospital Compare (Care Compare) star rating domains?
CLABSI rates are reported using this risk-adjusted metric.
What is the SIR (Standardized Infection Ratio)?
This High Reliability principle emphasizes resisting oversimplification.
What is "reluctance to simplify"?
This process is used to sort patients based on the urgency of their condition.
AGITER
What is triage?
The "second victim phenomenon" refers to this group affected by medical errors.
Who are healthcare providers (who experience emotional trauma after an error)?
The Vizient Quality & Accountability Scorecard emphasizes six domains. Name one besides mortality and safety.
What are effectiveness, efficiency, equity, or patient centeredness?
The bundle approach to prevent ventilator-associated events includes head-of-bed elevation, daily sedation interruption, and this hygiene step.
What is "oral care"
What is the single greatest reason student suicides are missed in outpatient college clinics?
What is failure to formally screen for suicide risk?
This life-threatening condition involves a dysregulated response to infection.
PISSES
What is sepsis?
What is the name of the system that promotes accountability and learning instead of blame.
What is "Just Culture"
Name the three types of metrics typically used in a quality improvement project.
What are process, outcome, and balancing measures?
In antimicrobial stewardship, the CDC’s "Core Elements" include leadership commitment, accountability, pharmacy expertise, and this activity.
What is "tracking and reporting antimicrobial use and resistance"?
In primary care, the Agency for Healthcare Research and Quality (AHRQ) emphasizes this model — originally from aviation — to improve communication and teamwork across clinicians and staff.
What is "TeamSTEPPS"?
Breakdowns in this process are a top cause of patient harm and safety events.
MOANCICIMTNUO
What is communication?
This international alliance, founded by WHO, set the first global patient safety challenges (like hand hygiene and safe surgery).
What is the WHO World Alliance for Patient Safety?
Donabedian’s model evaluates quality using three categories: structure, process, and this category.
What is "outcome"?
This term describes hospital infections that appear after 48 hours of admission and were not incubating on arrival.
What are "nosocomial infections" (or hospital-acquired infections, HAIs)?
During a significant outbreak on a college campus, rapid coordination across health services, administration, and public health relies on this 3-word type of emergency framework, also used in hospitals.
What is an "Incident Command System (ICS)"?
This core discipline focuses on preventing harm to patients during care.
TAPTNIE TAFESY