220 week3 -safety

define pt safety

reduction and mitigation of unsafe acts within the health care system and the use of best practice

REDUCING AND INTERCEPTING HARMFUL ACTS

define adverse event

harm to the patient

define no harm event

an event occured but no harm was done

define a near miss

good catch

couldve casued harm but intercepted before it reached the pt

define sentinel event

critical incident

significant physical impairment or loss of life

whata re the 4 most common adverse events

heathcare/meds 47%(med dosing error)

infection 31%

procedure related (18%)

patient accidents (4%) _ falls

blunt end error vs sharp end error

b; latent errors (flaws in the system)

s; active errors that occur during direct patient care (ex: wrong dose)

examples of diagnostic and treatment errors

d; delay in diagnosis

t; performance error during a clinical procedure

example of preventive errors

failure to provide prophylatic treatment and neglecting fall risk

what patient factors impact errors

age - developemnetal stage

imapired mobility

sensory or comunciation impairemnet

lack of safety awareness

what are the 4 components of the swiss cheese model

1 organization (executive)

2 evironment (workplace)

3 team protects (follow procedure)

4 indivdiual (bedside and fatigues management)

what is the iceberg model

teh direct cause/factors you can see are only whatys above the surface, near misses and unsafe acts lurk below the surface

what is the swiss cheese model showing (*the holes)

holes show the weakness in ecah area and that when all th eholes lined up its a systemic failure that leaf to an error

define harm reduction

id potential risks

what is root cause analysis

id underlying factors and sustem vulnerabilities (not just on the surface)

what is just culture

reporting without fear of punishment/judgement

what is intersectionality

recphgnizes people face multiple and overlapping forms of discrimination

what is ableism

pt is treated differently because of a disability

what are systemic barriers

racism, poverty, no ramps, language barrier

what is systems thinking

looking at the interaction of people, processes and environment