Lecture 16: A Culture of Patient Safety Flashcards
ISMP (Canada) The Institute for Safe Medication Practices Canada
Canadian Patient Safety Institute
what does it do?
The Institute for Safe Medication Practices Canada is an independent national not‐for‐profit organization committed to the advancement of medication safety
in all healthcare settings.
promote safe med practices
CPSI works with gov’t and organizations to improve pt safety and quality
which book breaks the silence that has surrounded medical errors and their consequences by not pointing fingers at individuals sets forth a national agenda for reducing medical errors and improving patient safety through the design of a safer health system
To Err is Human
Define culture of patient safety
A safety culture exists within an organization [when] each individual employee, regardless of their position, assumes an active role in error prevention and that role is supported by the organization.
what is described here:
view that most errors reflect predictable human failings in the context of poorly designed systems (e.g., expected lapses in human vigilance in the face of long work hours or predictable mistakes on the part of relatively inexperienced personnel faced with cognitively complex situations)
identify situations or factors likely to give rise to human error and implement systems changes
systems approach
what is described here:
personnel or parts of the health care system in direct contact with patients
administering any kind of therapy (e.g., a nurse programming an intravenous pump) or performing any aspect of care
sharp end
what is described here:
many layers of the health care system not in direct contact with patients, but which influence the personnel and equipment which do contact patients
consists of those who set policy, manage health care institutions, and design medical devices, and other people and forces, which, though removed in time and space from direct patient care, nonetheless affect how care is delivered
blunt end
what is described here:
An event or situation that did not produce patient injury, but only because of chance. This good fortune might reflect robustness of the patient (e.g., a patient with penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse happens to realize that a physician wrote an order in the wrong chart). This definition is identical to that for close call.
Need to be documented
Near miss
what is described here:
discipline that attempts to identify and address safety problems that arise due to the interaction between people, technology, and work environments.
human factors engineering
what is described here:
process of avoiding such inadvertent inconsistencies by reviewing the patient’s current medication regimen and comparing it with the regimen being considered for the new setting of care.
med reconciliation
explain the medication error iceberg
reported errors are errors that cause actual harm and is the tip of the glacier
- unreported errors make up what’s below the surface\
- Incidence in health care and med errors in health system is unknown
- Many near misses not talked about
explain the swiss cheese model
protective barriers are in place such as prescription checking, patient understanding treatment, complete prescription issued, effective communication from pros when necessary, accurate check when administered
- holes in system still exist and represent weakness and active failures, latent conditions
A person problem or a system
problem?
The person approach focuses on the errors made by individuals. The reaction to these errors tends to be to name, blame and shame. Although professionals must take responsibility for their actions, blaming does not encourage a culture of reporting or learning.
In order to function safely an organisation needs to understand its risks so that it can minimise them by building in defences and safeguards. These risks can only be identified if there is commitment to an open
culture of reporting throughout the organisation.
what is the systems approach?
accepts that humans are fallible and therefore
errors can be expected to occur – and may recur regardless of the competence of individuals
- focus on the conditions and how they predispose errors
- enables system defenses to be made
define drug incident
Any preventable event that may cause or lead to inappropriate drug use or patient harm. Drug incidents may be related to the practice of pharmacists, techs, drugs, health care products, aids/devices, procedures, systems ◦ Prescribing; ◦ Order communications; ◦ Product labeling, ◦ Packaging, nomenclature; ◦ Compounding; ◦ Dispensing and distribution ◦ Administration ◦ Education, monitoring and use.
define drug error
Means an adverse drug event or a drug incident where the drug has been released to pt
