Patient Safety Evolution
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"?
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)?
High Reliability Organizations are described as operating in this type of environment where failure is not tolerated.
What is "complex, high-risk industries" (like aviation, nuclear, healthcare)?
A patient receives the wrong chemotherapy dose because weight-based dosing was not verified. This is an example of error at which level: prescribing, dispensing, or administration?
What is "prescribing error"?
The Swiss Cheese Model of error prevention was developed by this psychologist.
Who is James Reason?
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)?
The five principles of HROs include preoccupation with failure and resilience. This principle emphasizes resisting oversimplification.
What is "reluctance to simplify"?
A hospital reduces door-to-balloon time for STEMI patients. This improvement aligns most with which IOM aim?
What is "timeliness"?
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 oral hygiene step.
What is "oral care with chlorhexidine"?
College health centers face rising demand for mental health care. A common safety risk is fragmented communication between campus providers and outside specialists. Embedding this type of consent process helps ensure continuity of care.
What is "shared or universal release of information" (to allow data sharing between providers)?
A community hospital reports higher sepsis mortality than expected. The first analytic step is adjusting for this factor.
What is "patient risk/severity of illness"
The Lucian Leape Institute is best known for advancing this movement in safety.
What is "systems thinking and patient safety reform"?
Under the Hospital-Acquired Condition Reduction Program (HACRP), hospitals in this lowest quartile lose 1% of Medicare payments.
What is the worst-performing quartile (bottom 25%)?
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"?
During a root cause analysis (RCA), the team uses a fishbone diagram. This tool is also known as what?
What is an "Ishikawa diagram" (or cause-and-effect diagram)?
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 outcome.
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 outbreaks like meningitis or COVID-19 on college campuses, rapid coordination across health services, administration, and public health relies on this type of emergency framework, also used in hospitals.
What is "Incident Command System (ICS)"?
What is the formal name of the IHI quality improvement model that uses PDSA?
What is "The Model for Improvement?"