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NUR 2243
- 1) Goal of IOM Report
Answer
Break status quo / cycle of inaction
b) Safety gaps will not be tolerated
c) Address resistance to change
d) Address insurmountable barriers
e) Ensure healthcare is of healing and comfort with no acceptance of harm
- IOM Comprehensive approach to healthcare quality and safety improvement created a
model which
includes
Answer
a) Domains of Quality
b) External Drivers (need to be balanced
- The domains of quality are
Answer
a) Safety/Safe care processes- freedom from accidental injury
b) Practice consistent with current medical knowledge (evidence based practice)
c) Customization (patient centered)
- 4) Issues that effect safety in healthcare 1 / 3
Answer
a) Misuse (most common)- avoidable complication
b) Overuse
c) Underuse
- 5) The external drivers that influence quality improvement
Answer
a) Regulatory and Legislative
b) Economics and other incentives
- 6) Definition of healthcare quality (quality and safety always go together CANNOT
separate)
Answer
a) Processes and outcomes that meet or exceed the needs and desires of the population
- 7) State of healthcare 1999
Answer
a) Medical errors 8th leading cause of death, estimated as much as 98K deaths annual
- An error is defined as the failure of a planned action to be completed as intended (i.e., error
of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).
They are a systems issue.
Answer 2 / 3
a) Class of errors
i) Diagnostic
ii) Treatment iii) Preventative failure (e.g. monitoring or follow-up) iv) Other failure (e.g. equipment)
b) Types of errors/Unsafe acts
i) Error in execution
(1) Slip-observable (wrote wrong drug) (2) Lapse- non observable (not remembering something) (3) Violation is unsafe act and deliberate although may feel justified
ii) Error in Planning 1 (1) Mistake, rule based or knowledge based- planned action was wrong, e.g. lack of knowledge or assessed incorrectly iii) Active error-felt immediate, at front line, frontline operator iv) Latent error-removed from direct control, in system, *pose greatest threat- e.g. poor design instillation, management structure
c) Most common medical error is medication error
- 9) Why do errors happen-Systems Approach
Answer
a) Multiple contributing factors
b) Complex systems- System-set of independent elements, both human and non- human,
interacting to achieve a common goal
c) Any element in system may belong to other systems
d) System failure- due to multiple failures that occur in an unanticipated interaction create
chain of events in which faults grow and evolve
e) Accident- event that involves damage to defined system that disrupts ongoing or future
output of that system, an unintentional incident
- Adverse event is an injury caused by medical management rather than the underlying
condition of
the patient. An adverse event attributable to error is a "preventable adverse event."
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