Certified Professional in Patient Safety,
CPPS Patient Safety Certification,
National Patient Safety Goals, Patient
Safety and Risk Management
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
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 safety in ambulatory care
1. role of pt and caregiver behaviors
2. role of provider-pt interactions
3. role of community and health system
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 achieved without
clear and high-quality communication between all providers
most common root cause of sentinel events
communication
elements that affect communication
1. rigid hierarchies
2. overtly disruptive and unprofessional behavior
3. nonverbal cues
4. interpersonal relations
5. group dynamics
communication tools
read-back protocols
SBAR
teamwork training
CDSS
Clinical Decision Support System
assist healthcare providers in the actual diagnosis and treatment of patients, analyze
data from clinical information systems
avoids commission and omission errors
unintended consequences of CPOE
1. more or new work for clinicians
2. unfavorable workflow
3. never-ending system demands
4. persistence of paper orders
, 5. changes in communication patterns and practices
6. neg towards new technology
7. new types of errors
8. change in power structure, org culture , or professional roles
High Reliability Organizations (HROs)
persistent mindfulness with in an organization
cultivate resilience by relentlessly prioritizing safety over other performance pressures
consistently minimize adverse events despite carrying out intrinsically complex and
hazardous work
safety is emergent vs. static
commitment to safety at all levels
HRO key features
1. know high-risk nature of activities and determine to have consistent safe operations
2. blame-free
3. collaboration across ranks and disciplines
4. commitment of resources to address safety concerns
Patient Safety Culture Surveys and Safety Attitudes Questionnaire
ask providers to rate the safety culture in their units and org as a whole
poor perceived safety culture= increased error rates
just culture
addressing systems issues that lead individual to engage in unsafe behaviors while
maintain accountability
human error (slip)
at risk behavior (short cuts)
reckless behavior (ignoring required safety steps)
Debriefing
dialogue to learn from defects and improve performance through goal discussion,
reflection to incorporate improvement or discover opportunities in future performance
simulation
real-life emergency responses
teamSTEPPS
Components of debriefing
1. setting the stage
2. description or reactions
3. analysis
4. application
plus delta debriefing
1. What went well?
2. What did not go well?
3. what can we do differently or what needs to change to improve care?
debriefing framework
team evaluates if:
had clear communication
understanding of roles & responsibilities
maintained situational awareness
distributed workload
CPPS Patient Safety Certification,
National Patient Safety Goals, Patient
Safety and Risk Management
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
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 safety in ambulatory care
1. role of pt and caregiver behaviors
2. role of provider-pt interactions
3. role of community and health system
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 achieved without
clear and high-quality communication between all providers
most common root cause of sentinel events
communication
elements that affect communication
1. rigid hierarchies
2. overtly disruptive and unprofessional behavior
3. nonverbal cues
4. interpersonal relations
5. group dynamics
communication tools
read-back protocols
SBAR
teamwork training
CDSS
Clinical Decision Support System
assist healthcare providers in the actual diagnosis and treatment of patients, analyze
data from clinical information systems
avoids commission and omission errors
unintended consequences of CPOE
1. more or new work for clinicians
2. unfavorable workflow
3. never-ending system demands
4. persistence of paper orders
, 5. changes in communication patterns and practices
6. neg towards new technology
7. new types of errors
8. change in power structure, org culture , or professional roles
High Reliability Organizations (HROs)
persistent mindfulness with in an organization
cultivate resilience by relentlessly prioritizing safety over other performance pressures
consistently minimize adverse events despite carrying out intrinsically complex and
hazardous work
safety is emergent vs. static
commitment to safety at all levels
HRO key features
1. know high-risk nature of activities and determine to have consistent safe operations
2. blame-free
3. collaboration across ranks and disciplines
4. commitment of resources to address safety concerns
Patient Safety Culture Surveys and Safety Attitudes Questionnaire
ask providers to rate the safety culture in their units and org as a whole
poor perceived safety culture= increased error rates
just culture
addressing systems issues that lead individual to engage in unsafe behaviors while
maintain accountability
human error (slip)
at risk behavior (short cuts)
reckless behavior (ignoring required safety steps)
Debriefing
dialogue to learn from defects and improve performance through goal discussion,
reflection to incorporate improvement or discover opportunities in future performance
simulation
real-life emergency responses
teamSTEPPS
Components of debriefing
1. setting the stage
2. description or reactions
3. analysis
4. application
plus delta debriefing
1. What went well?
2. What did not go well?
3. what can we do differently or what needs to change to improve care?
debriefing framework
team evaluates if:
had clear communication
understanding of roles & responsibilities
maintained situational awareness
distributed workload
