Safety & Injury Prevention in Healthcare

Flashcards about safety and injury prevention in health care.

Safety in Health Care

Freedom from accidental injury, avoiding injuries to patients from the care that is intended to help them, focusing on using evidence, Collaboration with patients and families to observe and report gaps or omissions in care to help avoid errors.

Quality and Safety Education for Nurses (QSEN)

Minimizing risk of harm to patients and providers through both system effectiveness and individual performance (competency).

Adverse event

Commission or omission, unintended harm not related to underlying disease or condition

Near miss

Commission - improper care provision, did not provide care.

Sentinel event

Unexpected occurrence involving death or serious injury.

Diagnostic Error

Delay in diagnosis, failure to employ tests, use of outmoded tests, failure to act on results.

Treatment Errors

Wrong treatment, avoidable delay

Preventative Errors

Failure to provide prophylactic treatment or inadequate monitoring or follow-up.

Communication failure

Lack of communication or lack of clarity in communication.

Active Error

Made by providers such as physicians, nurses, and technicians who are front- line in provision of patient care. Examples: giving wrong medication, wrong patient, wrong treatment.

Latent Error

Potential contributing factors that are hidden and lie inactive in the health care delivery system. Flaw in the system-does not lead to an immediate error but creates a situation that leads to a triggering event for an error (Swiss Cheese Model)

Human Error

Inadvertent action slip or lapse in practice.

At Risk Behavior

Behavior choice that increases risk by not knowing the risk or thinking that the action’s benefit outweighs the risk.

Reckless Behavior

Consciously disregard a substantial risk

Culture of Safety

Focus on patient outcomes instead of blame. Communication guided by mutual trust, shared perceptions of safety, and confidence that error prevention strategies will work. Acknowledges complexity of systems in health care and human factors that affect safety

Just Culture

A system’s explicit value of reporting errors without punishment. People can report mistakes without reprisal or personal risk.

Transparency in Health Care

The system allows for provision of information to patients and families that allows them to make informed decisions about where and from whom to receive their care. Transparency also means open communication and information sharing with patients and families, including about adverse and sentinel events

Error Reporting

Essential to harm prevention and a just culture.