Show:
Patient Safety Occurrence Reports
Root Cause Analysis (RCA)
Sentinel Event
Irish Trivia
100
What is the software system that supports Patient Safety Occurrence Reports (PSORs)?
Riskmaster.
100
What should you ask in an RCA until you can no longer?
Why, Why, Why?
100
Who is CHP’s Patient Safety Officer?
Ray Pitetti, MD
100
Where is the site of the first St. Patrick’s Day celebration?
Boston- 1737.
200
A PSOR should be entered within what amount of time of the identification of an incident?
24 Hours.
200
What is the name of the mechanism that provides for a proactive approach to preventing harm?
FMEA- Failure Mode Effects Analysis
200
What are periodic alerts with timely information about similar, frequently reported RCAs and SEs sent by JC with suggested actions for prevention?
Sentinel Event Alerts
200
What nationality was St. Patrick?
Born in Scotland- Mom was Scot, Dad was Italian.
300
What service had the most events deemed “serious” in CY 2016?
Surgical/Procedural.
300
Name one of the top two subject matters of RCAs at CHP in CY 2016....
Medications; MRI.
300
SE= a patient safety event that results in in one of three possible outcomes- name one...
death, permanent harm, severe temporary harm.
300
What is the official emblem of Ireland?
The Harp.
400
How many “serious” events were identified in CY 2016?
26.
400
Name one of the top three SEs as reported by JC in CY 2016...
wrong patient/site procedure; unintended retained foreign body; delay in treatment.
400
What was the most frequent patient outcome of SE’s reported to JC in 2016?
Death.
400
What is Ireland's national color?
Blue.
500
How many occurrence reports were submitted and reviewed in CY 2016?
9,816.
500
How many RCA’s were conducted in CY 2016?
16
500
If a patient committed suicide on the premises, that would be sentinel. If a patient committed suicide 72 hours post- discharge? Yes/No?
Yes- Sentinel Event.
500
What is the most common surname in Ireland?
Murphy.