Hospital Safety B/B

Flashcards covering key concepts in operating room safety, types of errors, prevention strategies, and related topics.

What are action-based errors?

Errors such as a needle being inserted into the wrong blood vessel, which can be avoided by practice and standardized techniques.

What are decision-based errors?

Errors involving knowledge-based or judgment errors.

What are communication-based errors?

Errors that can be avoided by preoperative briefing of the team.

What are Never Events?

Events that should never happen, without exceptions, like surgery on the wrong site or wrong patient.

Name some 'Never Events'.

Surgery on the wrong site/patient, wrong procedure, foreign object left inside, and administration of incompatible blood.

What are the key components of Wrong Site Surgery Prevention?

Verification of correct patient, site, and procedure at all stages and marking of operating sites.

When should verification take place in regards to Wrong Site Surgery Prevention?

When the procedure is scheduled, upon entry to the operating room, and immediately prior to starting the procedure.

Who should ideally mark operating sites?

The operating surgeon, ideally when the patient is awake to confirm.

What is a Time Out in the context of operating room safety?

A pause before a medical/surgical procedure where the patient, physician, nurses, and staff are all present to verify details.

What is verified during a Time Out?

Patient name, type of procedure, verification of side, site, and other details; all team members must agree to proceed.

What are Checklists in operating room safety?

Series of steps that must be done prior to a procedure, shown to reduce many adverse events.

What is Medication Reconciliation?

Process of identifying the most accurate list of medications, including name, dosage, frequency, and route.

When is Medication Reconciliation often done?

At care transitions like admission to a hospital or nursing home.

What is Antimicrobial Stewardship?

A hospital program that monitors the use of antibiotics to prevent drug-resistant bacteria and promote appropriate antibiotic use.

What are Infection Control Precautions?

Measures taken to prevent the spread of disease, including standard, droplet, contact, and airborne precautions.

What are Standard Precautions?

Hand washing, gloves when touching blood/body fluids, surgical mask/face shield if chance of splash/spray, and gown if skin/clothing exposed to blood/fluids.

What are Contact Precautions?

Gloves and gown for patients with infections easily spread by contact (e.g., infectious diarrhea, C. difficile, MRSA).

What are Droplet Precautions?

Facemask, gloves, and gown for patients with infections spread by large droplets (e.g., respiratory viruses, Neisseria meningitides).

What are Airborne Precautions?

Fit-tested mask or respirator, gloves, and gown for patients with infections spread by airborne particles (e.g., tuberculosis, measles, chickenpox).

Name some aerosol generating procedures.

Endotracheal intubation, bronchoscopy, open suctioning, non-invasive positive-pressure ventilation and cardiopulmonary resuscitation.

What is Root Cause Analysis?

A method to analyze serious adverse events (SAEs) to identify the direct cause of error plus contributors.

What is Failure Mode & Effects Analysis?

Identifying how a process might fail BEFORE an adverse event happens, and identifying the effects of potential failure.

What are Active Errors?

Errors that occur at the end of a process, often frontline/bedside operator error.

What are Latent Errors?

Errors away from bedside that impact care, such as poor staffing leading to overworked nurses.

Define "ameliorable" adverse events.

Not preventable but severity could have been reduced.

Define a "near miss" adverse event.

Error committed but not harm occurred.

Define "commission error".

Action caused harm.

Define "omission error".

Failure to act caused harm.

What is the Swiss Cheese Model?

Flaws at multiple levels align to cause serious errors, often more than just a single mistake.

What does PDSA stand for?

Plan-Do-Study-Act

Explain the PDSA cycle.

PLAN: Plan a change, DO: Implement the plan, STUDY: Study the outcome, ACT: Take action based on the study findings- which is repeated to generate continuous improvement.

What are Triggers in the context of patient care?

Patient events that mandate a response, such as new chest pain or low oxygen saturation.

What is a Rapid Response Team?

A provider group that responds to triggers with a formal assessment.

What are Forcing Functions?

Actions that “force” a beneficial action for safety, such as not being able to order meds until allergies are verified.

What is Human Factors Design?

Design of systems that accounts for how humans work and function, and how humans interact with the system.

Give examples of Human Factors Design.

Standardization and Simplification

What are the key elements of a Culture of Safety?

Safety as a priority, teamwork, openness and transparency, accountability, non-punitive responses, and education/training.

What is a High Reliability Organization?

Organizations that operate in hazardous conditions with a high potential for error but have fewer than average adverse events.