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
Commission
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
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
Commission
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
