National Patient Safety Goals
They publish the National Patient Safety Goal
What is The Joint Commission
The 1999 article To Err Is Human: Building a Safer Health System And the 2001 Crossing the Quality Chasm were written by this organization
What is the Institute of Medicine
The Harvard Business Review reported this number of patients were harmed by medical errors in 2021
What is 1.2 million
An event or situation that did not produce patient injury, but only because of chance. This good fortune might reflect robustness of the patient or a fortuitous, timely intervention.
What is a Close Call
Errors that occur during tasks that rely heavily on sensory information which is obscured, ambiguous, or degraded because of impoverished environmental conditions or diminished sensory system Is it a perceptual error, a skill based error, a exceptional violation, a decisional error or a routine violation
What is a Perceptual errors
Designing for Zero is the VA's answer for the 6th National Patient Safety Goal
What is Reduce Risk for suicide
James Reason invented The Theory of Active and Latent Failures but it is better know as this
What is The Swiss Cheese Model
On Average it takes this many years for hospitals to incorporate EBM
What is 17 years
A non-threatening conversation that is conducted to review a procedure or event
What is a Debrief
errors that occur frequently during highly practiced activities and appear as attention failures, memory failures, or errors associated with the technique with which one performs a task Is it a perceptual error, a skill based error, a exceptional violation, a decisional error or a routine violation
What is a Skilled based error
This is the 2022 first National Patient Safety Goal?
What is Identify Patients correctly using two patient identifiers?
The person is the first to use charts and graphs to show the relationship between hygiene and patient outcomes during the Crimean War.
Who is Florence Nightingale
There is a 1 in a million chance of a person being harmed while travelling by plane. In comparison, there is a 1 in this chance of a patient being harmed during health care.
What is 1 in 300
In an HRO, all employees, regardless of rank or title, are empowered to speak up in the interest of patient safety. We ask that when there is a concern a staff member does this
What is stop the line?
isolated departures from authority, neither typical of the individual nor condoned by management Is it a perceptual error, a skill based error, a exceptional violation, a decisional error or a routine violation
What is an Exceptional violations:
Marking surgery sites helps to do this per the national patient safety goal
What is Reduce Surgical Errors
In 1919 they developed the first set of hospital standards, which was one page long, and began on-site inspections.
Who are the American College of Surgeons (ACS)
This is the number 1 patient safety concern from a hospital perspective in 2022
What is shortage of clinical and nonclinical staff across the continuum.
The degree to which one's perception of a situation matches reality.
What is Situational Awareness
errors typically result from a lack of information, knowledge, or experience Is it a perceptual error, a skill based error, a exceptional violation, a decisional error or a routine violation
What is are Decision errors:
This is what is done when patients, staff and providers, Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient.
What is Medication Reconciliation
In 2007 This organization spearheaded a project aimed at reducing MRSA infections, specifically aimed at prevention and contact with patients. The Centers for Disease Control and Prevention (CDC) noted a ⅔ decrease in the amount of MRSA infections for this organization from 2005-2017.
What is Department of Veteran Affairs (yeah us!)
Of Nursing Homes, Ambulatory Care, or Acute Care hospitals this type of health care reports the most amount injuries to staff from day to day care of patients
What is ambulatory Care
A common process used to prospectively identify error risk within a particular process. It begins with a complete process mapping that identifies all the steps that must occur for a given process to occur then continues by identifying the ways in which each step can go wrong the probability that each error will be detected and the consequences or impact of the error not being detected. The estimates of the likelihood of a particular process failure, the chance of detecting such failure, and its impact are combined numerically to produce a criticality index.
What is a HFMEA Health Care Failure Mode Analysis
often referred to as “bending the rules”; a type of violation that tends to be habitual by nature, engaged in by others, and tolerated by supervisor and management. Is it a perceptual error, a skill based error, a exceptional violation, a decisional error or a routine violation
What are Routine violations