Acronyms
What does IOM stand for?
Institute of Medicine: A nonprofit organization established in 1970 as a component of the US National Academy of Sciences that works outside the framework of government to provide evidence-based research and recommendations for public health and science policy. The mission of the Institute of Medicine is to advance and disseminate scientific knowledge to improve human health.
Patient safety moved to the forefront in health care with the release in 1999 of the Institute of Medicine (IOM) landmark report titled:
Answer: B. To Err is Human: Building a Safer Health System. This report estimated that annually in the United States, up to one million people were injured and 98,000 died as a result of medical errors (IOM, 2000).
The concept of medical harm has existed since antiquity (e.g., Hippocrates). What is the term used for medical harm?
Iatrogenesis
_________ remain central to providing an environment and culture of safety.
A. Everyone
B. Physicians
C Nurses
C. Nurses
According to the follow-up research studies on preventable deaths or premature deaths a year, adverse health outcomes associated with medical errors has increased to:
A. 200,000 deaths
B. 300,000
C. 400,000
C. 400,00 (1,096 deaths a day or 3 747 airplanes crashing each day
What does TJC stand for?
An independent, not-for-profit organization, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. Vision Statement: All people always experience the safest, highest quality, best-value health care across all settings.
In 2013, the estimates of patient harms associated with hospital care were assessed (James, 2013). The number of premature deaths associated with preventable harm to patients decreased or increased?
Answer: Increased. the number of premature deaths associated with preventable harm to patients to be more than 400,000 per year and that serious harm appeared to be 10 to 20 times more common than deaths. Every year 400,000 deaths occur and 4 to 8 million occurrences of serious harm translate into 1,096 deaths and 10,959 to 20,918 occurrences of serious harm daily.
An adverse patient event (adverse event) is:
Answer: A. A preventable healthcare error: Investigators in the Harvard Medical Practice Study defined an adverse event as "an injury that was caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced a disability at the time of discharge, or both."
In the Landmark report from the Institute of Medicine, To Err is Human: Building a Safer Health System in 1999, how many people are injured each year due to medical errors?
A. 500,000
B. 1 million
C. 2 million
B. 1 million
In 2002, The Joint Commission (TJC) established National Patient Safety Goals (NPSG)to improve patient safety. True or False?
True
What does the NPSGs stand for?
In 2002, The Joint Commission established National Patient Safety Goals to improve patient safety by assisting healthcare organizations to address specific areas of concern with regard to patient safety. The Joint Commission determines the highest priority patient safety issues and how best to address them. Examples on in Ulrich and Kears (2014) on page 448
There are several types of preventable errors made in the healthcare system. Can you name one type of error?
Answer: Preventable adverse events include errors of commission, errors of omission, errors of communication, errors of context, and diagnostic errors (James, 2013).
___________ is the culmination of individual and organizational attitude, beliefs, perceptions, competencies and patterns of behavior in the workplace.
A. Safety Culture
B. Just Culture
Answer: A. Safety culture is the culmination of individual and organizational attitude, beliefs, perceptions, competencies and patterns of behavior in the workplace.
In this same IOM 1999 Landmark report, how many people die each year from medical errors?
A. 98,000
B. 50,000
C. 150,000
A. 98,000
The IOM recommended that all healthcare professionals work on how many specific competencies?
A. 4
B. 5
C. 6
C. 6
What does QSEN stand for?
The Quality and Safety Education for Nurses (QSEN) project, created in 2006, developed a quality and safety framework to be integrated into nursing education. The framework was based on recommendations from the IOM (2003) to prepare all health professionals with six core competencies: Patient centered care, teamwork and collaboration, evidence-based care, quality improvement, safety, and informatics.
Failing to do the right thing is an act of commission. True or False?
False. An error of commission is doing something wrong. An error of omission is failing to do the right thing.
Near miss: an unsafe situation that is indistinguishable from a preventable adverse event except for the outcome. A patient is exposed to a hazardous situation but does not experience harm either through luck or early detection.
Ulrich & Kear (2014) suggest that inattention to patient context is an underrecognized cause of medical error (“contextual error”), that detecting its presence usually requires listening in on the visit, and that it has significant implications for quality of care.
Methicillin-resistant Staphylococcus aureus (MRSA) infections decreased in the United States from 2005-2011. True or False?
True. Hospital-acquired infections dropped by 54% (Ulrich & Kear, 2014). "This decline was likely due to increased awareness, major infection control initiatives, and reimbursement incentives/disincentives" (pp. 449-450)
In an update to the IOM Landmark report, researchers found that preventable adverse events include 4 types of errors as well as diagnostic errors such as:
Errors of omission-Errors of commission
Errors of communication-Errors of context
List two of the 6 core competencies of Quality and Safety Education for Nurses (QSEN).
What does CONHI stand for?
College of Nursing Health Innovation
Adverse health outcomes affect people and
____________ more
A. Hospitals
B. Community
B. Community- when an adverse outcome occurs the community is affected the most due to safety responsibilities
Sentinel Event
a patient safety event that results in death, permanent harm, or severe temporary harm
Which is not a QSEN competency
A. Safety
B. Informatics
C. Quality Assurance
C. Quality Assurance- Quality Improvement is a the QSEN compentency
QSEN competency that nurses use as a guide to aid in practice
Evidence Base Practice