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 Cross -monitoring (asked and offered help prn) Made, mitigated, or corrected errors Detecting errors and safety hazards goal to prospectively id hazards before pt harmed and analyzing events that have occurred to id and address underlying systems flaws Fmea failure mode and effects analysis 1. Identify all process steps "process mapping" 2. How each step can go wrong "failure modes" 3. Impact of each error 4. Likelihood of process failure 5. Chance of detecting failure 6. Impact of error Swift structured what -if technique
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