Definitions and Types
What is a medical error?
A preventable adverse effect of care, whether or not it is harmful to the patient.
Why is full disclosure to patients after an error important?
It maintains trust, supports ethical practice, and aligns with professional duty.
What principle is violated when a provider hides an error?
Autonomy
What is one way technology reduces medication errors?
Computerized order entry or barcode medication administration help in preventing medication mistakes and keeps patient info in one system
A nurse fears being punished for reporting an error. What culture should leadership promote?
A just culture
What is the "Swiss cheese model" in patient safety?
A model showing how system failures align to cause harm despite multiple safeguards.
True or False: Apologizing increases the risk of malpractice litigation (ex: lawsuit)
False: apologies do not prevent lawsuits, but they can aid in de-escalation in combination with other strategies
Which ethical principle emphasizes doing no harm?
nonmaleficence
Name one system-based cause of error
Poor communication
inadequate staffing
unclear protocols
workflow inefficiencies
During a busy clinic day, a minor procedure is performed on the wrong limb because the time-out checklist was skipped. What are the next steps?
A pre-procedure “time-out” and site marking prevent wrong-site errors. Afterward, the team must disclose the error, document it, and complete a root cause analysis
What term describes injury caused by medical management rather than the underlying disease?
an adverse event
Which organization advocates open disclosure and apology after adverse events?
The Joint Commission
When should a PA report a colleague’s repeated unsafe behavior?
when it compromises patient's safety
What is the purpose of a Just Culture environment?
Encourages reporting of errors without fear of punishment while maintaining accountability
A PA student documents under the wrong patient chart after copying and pasting notes. What steps should the provider take to correct this charting error?
Amend the record with a dated addendum noting the correction, report the incident, and reinforce EHR safety practices to prevent recurrence