Definitions in patient safety
Detecting and reporting Errors
Tools used in QI
Methods to reduce errors
Priniciples of QI
100
Adverse Event
What is an injury that results form a medical intervention or event that results in unintended harm because of an act of commission or omission rather than the underlying disease or condition
100
Safety reporting system, chart reviews, audits
What are methods for identifying and reporting adverse events
100
Aims statement
What is the statement used to define a Quality improvment project with clear objectives, and time frame with achievable goals
100
A useful process for understanding and solving a problem. Figure out what negative events are occurring. Then, look at the complex systems around those problems, and identify key points of failure
What is Root Cause Analysis
100
Raise awareness and improve working knowledge of pediatric patient-safety issues and best practices throughout the pediatric community. Act and advocate to minimize preventable pediatric medical harm by using information on pediatric-specific patient-safety risk Improve health care outcomes for children by adhering to proven best practices for improving pediatric patient safety
What are key principles of patient safety
200
near miss event
What is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so.
200
Time Out before a procedure, SBAR communication, Situational awareness (PEWS)
What are tools used to prevent adverse events in Pediatric patients
200
This tool of quality improvement is to establish a functional or causal relationship between changes in processes (specifically behaviors and capabilities) and outcomes.
What is a PDSA cycle
200
1. Identify the event to be investigated and gather preliminary information 2. Charter and select team facilitator and team members 3. Describe what happened 4. Identify the contributing factors 5. Identify the root causes 6. Design and implement changes to eliminate the root causes
What are the steps in a RCA analysis
200
lack of a clearly stated, shared, and measurable purpose; • role and leadership ambiguity; • team too large or too small; • team not composed of appropriate professionals; • need for orientation for new members; • lack of framework for problem discovery and resolution; • difference in levels of authority, power, expertise, • traditions/professional cultures, particularly medicine’s history of hierarchy; • lack of commitment of team members; • different goals of individual team members; • inadequate decision making; and • conflict regarding individual relationships to the patient/client.
What are barriers to teamwork
300
Preventable adverse event
What is an adverse event injury that could have been avoided as a result of an error or system design flaw.
300
Limited English proficiency: Medication reconcilliation, patient discharge, Informed consent, Emergency room Care, Surgical care
What are situations presenting high risk for adverse evnts in the managment of pediatric patients.
300
A diagram that uses graphic symbols to depict the nature and flow of the steps in a process
What is a flow chart
300
Use of SBAR Use of Team Huddles Daily Goal sheets
What are strategies to improve communication
300
• Pre-contemplation: People don’t even consider changing, which may manifest as a form of denial. • Contemplation: People think about the change, but giving up established behavior patterns gives them a feeling of loss. During this stage, people assess barriers (e.g., time, expense, hassle, fear, “I know I need to, but...”) as well as the benefits of change. • Preparation: People make the decision to change. They may experiment with small changes as the willingness to change increases. • Action: People take action to change (although if the prior stages have been neglected, action itself is insufficient). • Maintenance and relapse prevention: People take the required steps to sustain new behaviors.
What are the psychology of change steps
400
Sentinel event
What is an Event defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness
400
Professional repercussions of disclosure, legal liability, blame, lack of confidentiality, negative patient or family reaction, humiliation, perfectionism, guilt, lack of anonymity, and the absence of a supportive forum for disclosure
What are barriers to reporting adverse events
400
A cause and effect diagram,that is a graphic tool used to explore and display the possible causes of a certain effect. This diagram uses categories of Materials, Methods, Equipment, Environment, and People. Use a process-type cause and effect diagram to show causes of problems at each step in the process.
What is a fish bone diagram
400
Educational barriers Organizational barriers Psychological barriers
What barriers to effective team communication
400
What are we trying to accomplish? How do we know that a change is an improvement? What changes can we make that will result in improvement? PDSA
What are components of the Langley Model for Improvement
500
common causes of adverse events in Pediatric patients
What are medication errors,( including patient identification) delays or errors in diagnosis, errors in administration or method used for a treatement
500
Identify patients correctly, Improve staff communication, Use medicines safely, use alarms safely, Prevent infection, identify patient safety risks, prevent mistakes in surgery
What are the National Patient safety Goals to improve patient safety
500
They help improvement teams formulate aims by depicting how well (or poorly) a process is performing. They help in determining when changes are truly improvements by displaying a pattern of data that you can observe as you make changes. They give direction as you work on improvement and information about the value of particular changes.
What is a Run Chart
500
Typical events are: a) A malfunction or deterioration in the characteristics or performance. A malfunction or deterioration should be understood as a failure of a device to perform in accordance with its intended purpose when used in accordance with the manufacturer's instructions. The intended purpose means the use for which the device is intended according to the data supplied by the manufacturer on the labeling, in the instructions and/or in promotional materials. b) An inadequate design or manufacture.This would include cases where the design or manufacturing of a device is found deficient. c) An inaccuracy in the labeling, instructions for use and/or promotional materials. Inaccuracies include omissions and deficiencies. Omissions do not include the absence of information that should generally be known by the intended users.
What are events involving a medical device and criteria for reporting to the FDA
500
EQUIPP Training residents on QI and patient safety Poster presentations on a group or solo QI project
What are methods to meet MOC requirements for QI
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