Certified Professional in Patient Safety, CPPS Patient Safety Certification, National Patient Safety Goals, Patient Safety and Risk Management CBPPS Exam

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