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Terms in this set (201)
iatrogenesis Greek for originating from a physician
preventable adverse events those that occurred due to error or failure to
apply an accepted strategy for prevention
Ameliorable adverse event events that, while not preventable, could have
been less harmful if care had been different
adverse events due to negligence those that occurred due to care that falls
below the standards expected of clinicians in
the community
near miss an unsafe situation that is indistinguishable from
a preventable adverse event except for the
outcome - exposed but does not experience
harm either through luck or early detection
error broader term referring to any act of
commission or omission that exposes patients
to a potentially hazardous situation
,adverse event An injury caused by medical management
(rather than the underlying disease) and that
prolonged the hospitalization, produced at
disability at the time of discharge, or both
commision doing something wrong
omission failing to do the right thing
CPOE Computerized Provider Order Entry
2009 HITECH Act and meaningful use program
computer alerts three main 1. modestly effective at best
findings 2. alert fatigue is common
3. fatigue increases with exposure and heavier
use of CPOE systems
minimize alert fatigue 1. increase alert specificity to reduce
inconsequential alerts
2. tier alerts according to severity
3. make only high level/severe alerts
interruptive
4. use human factors principles
three concepts that influence 1. role of pt and caregiver behaviors
safety in ambulatory care 2. role of provider-pt interactions
3. role of community and health system
Medical Office Survey on Pt designed to assess safety culture in amb care
Safety Culture and data is available from AHRQ
, Pt Engagement 1. ed pt about their illness and medications with
pt demonstrating understanding "teach back"
2. empowering to act as a safety double check
checklist Algorithmic listing of actions to be performed
for a given clinical procedure designed to
ensure that no matter how often performed by
a given clinician, no step will be forgotten
reduce risk of slips
consensus of required behaviors
slips failure of schematic (autopilot) behaviors
lapses in concentration, distractions, or fatigue
mistake failures in attentional behavior
lack of experience or insufficient training
Situational Awareness the ability to access and track relevant to the
task,
comprehend the data,
forecast what may happened based on the
data, and
formulate an appropriate plan in response
situational awareness cannot be clear and high-quality communication between
achieved without all providers
most common root cause of communication
sentinel events