Term
| measuring error current system |
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Definition
complex
duplicative
sentinel events
discoverable |
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Term
| measuring errors conclusion |
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Definition
current system of reporting errors works inefficiently
not enough measures reported |
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Term
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Definition
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Term
| What is a sentinel event? |
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Definition
| unexpected occurrence involving death or serious physical or psychological injury or risk thereof |
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Term
| examples of sentinel events |
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Definition
death from med error
suicide
wrong limb surgery
incompatible blood transfusion |
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Term
| What is root cause analysis |
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Definition
| process for identifying the basic or contributing causal factors that underlie variations in performance associated with adverse events or close calls |
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Term
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Definition
| causal statements must clearly show the cause and effect relationship |
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Term
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Definition
| negative descriptors are not used in causal statements |
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Term
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Definition
| each human error must have a preceding cause |
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Term
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Definition
| each procedural deviation must have a preceding cause |
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Term
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Definition
| failure to act is only causal when there was a pre-existing duty to act |
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Term
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Definition
something that happened to a patient, member of staff or the general public
a clinical outcome with harmful or potentially harmful effects |
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Term
| What are the steps in RCA? |
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Definition
identify the incident
frame the problem
decide who will carry out investigation
data gathering plan and organize
determine chronology
identify care delivery problems
identify contributory factors
identify themes and develop improvement strategy
general report
act |
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Term
| % adverse events out of all hospital stays |
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Definition
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Term
| % negligent injuries out of all hospital stays |
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Definition
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Term
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Definition
advised to sue by influential other
needed money
believed there was a cover up
child would have no future
needed information
wanted revenge, license |
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Term
| why do some physicians get sued more than others? |
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Definition
attract a litigation prone population
attract medically high risk patients
technically incompetent
have difficulty connecting with patients |
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Term
| process of office of patient affairs |
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Definition
patient complains
patient advocate responds
record filed
MD, staff, admin, RM contacted |
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Term
| ______% of MDs account for _____% of complaints |
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Definition
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Term
| elements of basic interventions |
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Definition
invite to take some weeks to ID potential ways to address concerns
review content letter
express appreciation and acknowledge contribution
provide follow up data in 12 months |
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Term
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Definition
involve authority figure
review data
develop a plan
follow up on outcomes |
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Term
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Definition
dept chair, chief of staff, pcmc
continue previous plan and follow up
counsel pursuant to by-laws
corrective action as in manual
continued monitoring |
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Term
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Definition
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Term
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Definition
| National Patient Safety Goals |
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Term
| National Patient Safety Goals were established in _____? |
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Definition
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Term
| First set of NPSG effective _____? |
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Definition
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Term
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Definition
| Catheter associated urinary tract infections |
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Term
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Definition
| improve the accuracy of patient identification |
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Term
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Definition
| Improve the effectiveness of communication among caregivers |
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Term
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Definition
| Improve the safety of using medications |
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Term
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Definition
| Reduce the risk of health care associated infections |
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Term
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Definition
| Reduce the risk of patient harm resulting from falls |
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Term
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Definition
| Prevent health care associated pressure ulcers |
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Term
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Definition
| The organization identifies safety risks inherent in its patient populations |
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