Certified Professional in-
Patient Safety Exam
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
Commission
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
Patient 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
Patient Safety Exam
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
Commission
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
Patient 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
