Certified Professional in Patient Safety 2023 update questions and answers

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 findings 1. modestly effective at best 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 safety in ambulatory care 1. role of pt and caregiver behaviors 2. role of provider-pt interactions 3. role of community and health system Medical Office Survey on Pt Safety Culture designed to assess safety culture in amb care 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 achieved without clear and high-quality communication between all providers most common root cause of sentinel events communication elements the 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 process for prescribing and adm meds 1. order 2. Transcribing 3. dispensing 4. administration 90% errors occur at ordering (48%) or transcribing thus CPOE prevent 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 id and 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 sit 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. id 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 perceived safety problems can be detected through safety culture surveys executive walk rounds techniques to retrospectively id safety hazards 1. screen larger datasets for evidence of preventable adverse events that merit further investigation (trigger tools, patient safety indicators) 2. analyze individual cases of adverse events (RCA, mortality reviews, in-depth investigation) Patient Safety and Quality Improvement Act Jan 2009 confidential and privilege protections for pt safety info when HCP work with Patient Safety Organizations hazard detection methods voluntary error reports malpractice claims pt complaints executive walk rounds risk mgmt. database per Harvard Medical Practice Study, what % of errors were diagnostic 17% 9% were undetected while pt was alive heuristics Mental shortcuts or "rules of thumb" that often lead to a solution (but not always) availability heuristic dx of current pt biased by experience with past cases (crushing chest pain=MI) anchoring heuristic relying on initial dx impression despite subsequent info to the contrary (BC with corynebacterium txed as contaminant when endocarditis) framing effects dx decision making unduly biased by subtle cues and collateral information (addicted pt with abd pain tx for withdrawal but had bowel perf) blind obedience undue reliance on test results or expert opinion (false neg rapid Strept test) prominent reason for malpractice claims missed or delayed dx predisposing factors for dx error in ES and surgery poor teamwork communication gold standard for diagnosis autopsy goals is to have 25% inpt deaths autopsied prevent dx errors 1. info technology hoen triage 3. teamwork & communication training 4. increased supervision of trainees mega-cognition cognitive psychology reflect on own thinking with the hope to catch own misuse of heuristics before cause harm components of disclosure that matter most to pts 1. disclosure of all harmful errors 2. explanation why occurred 3. how error's effects will be minimized 4. steps taken to proven recurrences Full Disclosure Principle disclose all circumstances and events, acknowledgement of responsibility, and apology fewer malpractice lawsuits and lower litigation cost CANDOR Communication and Optimal Resolution used with disclosure of events % who reported witnessing physicians engage in disruptive behavior vs. nurses 77% 65% physician disruptive and disrespectful behavior impact on nursing dissatisfaction and likelihood of leaving nursing profession adverse events in OR % of healthcare professionals at any level engage in disruptive behavior 2-4% disruptive behavior disrespect for others interpersonal interaction that impedes the delivery of pt care subverts the org ability to develop a culture of safety (impacts teamwork and blame-free environment) unprofessional behavior in medical school is linked to subsequent disciplinary action by licensing board founder of patient safety movement Dr. Lucian Leape prevent disruptive behavior code of conduct defines and managing behaviors leadership in ensuring culture of safety prevent behavior Bell Commission 1987 mandating residents at New Your hospitals should work no more than 80 hours per week and no more than 24 consecutive hours due to Libby Zion's death due to med prescribing error Accreditation Council for Graduate Medical Education rules for work hours in 2003 1. no more than 80 hours per week 2. no more than 24 consecutive hours on duty 3. not be on call more than every 3rd night 4. must have 1 day off per week