Key concepts in patient safety

1. Key concepts in patient safety Understanding the problems and solutions related to patient safety requires understanding the concepts behind these terms: Adverse event Close call Error Human factors Latent errors Malpractice Medical error Near-miss Negligence Patient safety Potential AE Preventable AE Risk management System Introduction to Patient Safety Slide 12 Notes Key concepts in patient safety This is a short list of terms commonly used in relation to patient safety. Some are synonyms, but many are ambiguous, or are interpreted differently by by different groups. . Since it�s unlikely we�ll all have the same definition of patient safety concepts, it�s important to understand that individuals coming together to address PS issues need to be sure they have a common terminology.Introduction to Patient Safety Slide 12 Notes Key concepts in patient safety This is a short list of terms commonly used in relation to patient safety. Some are synonyms, but many are ambiguous, or are interpreted differently by by different groups. . Since it�s unlikely we�ll all have the same definition of patient safety concepts, it�s important to understand that individuals coming together to address PS issues need to be sure they have a common terminology.

2. Introduction to Patient Safety Slide 13 Notes Adverse Event (definition) Identifying something as an adverse event does not imply �error,� �negligence,� or poor quality care. It simply indicates that an undesirable clinical outcome resulted from some aspect of diagnosis or therapy, not an underlying disease process. (AHRQ) Introduction to Patient Safety Slide 13 Notes Adverse Event (definition) Identifying something as an adverse event does not imply �error,� �negligence,� or poor quality care. It simply indicates that an undesirable clinical outcome resulted from some aspect of diagnosis or therapy, not an underlying disease process. (AHRQ)

3. Close call (definition) An event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. Also known as near miss or near hit. Introduction to Patient Safety Slide 14 Notes Close call (definition) This good fortune might reflect robustness of the patient (e.g., a patient with penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse happens to realize that a physician wrote an order in the wrong chart). (AHRQ) Introduction to Patient Safety Slide 14 Notes Close call (definition) This good fortune might reflect robustness of the patient (e.g., a patient with penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse happens to realize that a physician wrote an order in the wrong chart). (AHRQ)

4. Error (definition) An act of commission or omission that leads to an undesirable outcome or significant potential for such an outcome. Error in judgment: Error related to flawed reasoning. Error of negligence: Error due to inattention or lack of obligatory effort. Introduction to Patient Safety Slide 15 Notes Error (definition) Error of commission: An error which occurs as a result of an action taken (e.g., a drug is administered at the wrong time, surgery performed on the wrong side of the body, transfusion using blood cross-matched for another patient. (JCAHO 2001) Error of omission: An error which occurs as a result of an action not taken, (e.g., a delay in performing an indicated cesarean section, a patient suicide is associated with a lapse in carrying out frequent patient checks. (JCAHO 2001)Introduction to Patient Safety Slide 15 Notes Error (definition) Error of commission: An error which occurs as a result of an action taken (e.g., a drug is administered at the wrong time, surgery performed on the wrong side of the body, transfusion using blood cross-matched for another patient. (JCAHO 2001) Error of omission: An error which occurs as a result of an action not taken, (e.g., a delay in performing an indicated cesarean section, a patient suicide is associated with a lapse in carrying out frequent patient checks. (JCAHO 2001)

5. Human factors (definition) Study of the interrelationships between humans, the tools they use, and the environment in which they live and work. Introduction to Patient Safety Slide 16 Notes Human Factors (definition) This is the study of interactions of humans with one another, with machines and with the environment in which they work. The human factors approach has recently been applied to the study of medical accidents�Introduction to Patient Safety Slide 16 Notes Human Factors (definition) This is the study of interactions of humans with one another, with machines and with the environment in which they work. The human factors approach has recently been applied to the study of medical accidents�

6. Latent errors (definition) Errors in the design, organization, training, or maintenance that lead to operator errors and whose effects typically lie dormant in the system for lengthy periods of time. Latent failures cannot be foreseen but, if detected, they can be corrected before they contribute to mishaps. Introduction to Patient Safety Slide 17 Notes Latent errors (definition) The term recognizes the fact that accidents often result from a series of errors, often spread out over time. These are "accidents waiting to happen", errors that are virtually offered by the system. This kind of progression of multiple errors in procedures, performance and equipment is seen in many accidents in complex systems. In the 1986 Chernobyl reactor accident, for example, most of the safety systems had been turned off because they were running some test experiments. Similar situations occurred at Three-Mile Island (1979) and Bhopal (1984). In all of these cases, a particular context and sequence of events, sometimes spanning months, lead up to the accident. The net effect is that the system virtually elicits the error from the user. Introduction to Patient Safety Slide 17 Notes Latent errors (definition) The term recognizes the fact that accidents often result from a series of errors, often spread out over time. These are "accidents waiting to happen", errors that are virtually offered by the system. This kind of progression of multiple errors in procedures, performance and equipment is seen in many accidents in complex systems. In the 1986 Chernobyl reactor accident, for example, most of the safety systems had been turned off because they were running some test experiments. Similar situations occurred at Three-Mile Island (1979) and Bhopal (1984). In all of these cases, a particular context and sequence of events, sometimes spanning months, lead up to the accident. The net effect is that the system virtually elicits the error from the user.

7. Malpractice (definition) Liability based on acts or omissions in the provision of health care or professional services. Introduction to Patient Safety Slide 18 Notes Malpractice (definition) While the term implies an intentional act, the term �malpractice� is frequently applied to all medical errors and all unexpected outcomes, including those events in which the health care provider acted appropriately. Thus someone mentioned as a �victim of malpractice� may not have encountered treatment outside the standard of care.Introduction to Patient Safety Slide 18 Notes Malpractice (definition) While the term implies an intentional act, the term �malpractice� is frequently applied to all medical errors and all unexpected outcomes, including those events in which the health care provider acted appropriately. Thus someone mentioned as a �victim of malpractice� may not have encountered treatment outside the standard of care.

8. Medical error (definition) An adverse event or near miss that is preventable with the current state of medical knowledge. Introduction to Patient Safety Slide 19 Notes Medical error (definition) No notesIntroduction to Patient Safety Slide 19 Notes Medical error (definition) No notes

9. Near miss (definition) An event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. Also known as close call or near hit. Introduction to Patient Safety Slide 20 Notes Near miss (definition) A situation in which an event or omission, or a sequence of events or omissions, arising during clinical care fails to develop further, whether or not as the result of compensating action, thus preventing injury to a patient. A near miss is an excellent opportunity to correct a latent error before it leads to actual patient harmIntroduction to Patient Safety Slide 20 Notes Near miss (definition) A situation in which an event or omission, or a sequence of events or omissions, arising during clinical care fails to develop further, whether or not as the result of compensating action, thus preventing injury to a patient. A near miss is an excellent opportunity to correct a latent error before it leads to actual patient harm

10. Negligence (definition) A legal theory based on the duty of an individual to act and use such care as a reasonably prudent person would do in the same or similar circumstances. In medical malpractice lawsuits, the plaintiff must prove: a duty, a breach of the standard of care, ascertainable damages, and direct causation between the breach of the standard of care and the damages. Introduction to Patient Safety Slide 21 Notes Negligence (definition) Expert testimony is usually required to establish the applicable standard of care when medical malpractice due to negligence is alleged. Duty = clinician has established a relationship with the patient and responsibility for his or her care Breach = behavior unreasonable for a clinician with that duty in that setting Damages = physical or emotional injury, inconvenience (e.g., extended hospitalization), loss of work, etc. Causation = a direct link between the negligent act (or omission) and the damagesIntroduction to Patient Safety Slide 21 Notes Negligence (definition) Expert testimony is usually required to establish the applicable standard of care when medical malpractice due to negligence is alleged. Duty = clinician has established a relationship with the patient and responsibility for his or her care Breach = behavior unreasonable for a clinician with that duty in that setting Damages = physical or emotional injury, inconvenience (e.g., extended hospitalization), loss of work, etc. Causation = a direct link between the negligent act (or omission) and the damages

11. Patient safety (definition) Actions undertaken by individuals and organizations to protect health care recipients from being harmed by the effects of health care services. Introduction to Patient Safety Slide 22 Notes Patient safety (definition) Freedom from accidental or preventable injuries produced by medical care. The avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of health care. A subset of health care quality. Sometimes synonymous to risk management, loss prevention, quality.Introduction to Patient Safety Slide 22 Notes Patient safety (definition) Freedom from accidental or preventable injuries produced by medical care. The avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of health care. A subset of health care quality. Sometimes synonymous to risk management, loss prevention, quality.

12. Potential adverse event (definition) An event, situation, or process that has the potential to contribute to a patient or visitor injury. Introduction to Patient Safety Slide 23 Notes Potential adverse event (definition) Reportable occurrences can generally be divided into: sentinel events, patient and visitor injuries, nears misses, and safety concerns Introduction to Patient Safety Slide 23 Notes Potential adverse event (definition) Reportable occurrences can generally be divided into: sentinel events, patient and visitor injuries, nears misses, and safety concerns

13. Preventable adverse event (definition) Patient harm that, given the current stateof medical knowledge, could have been prevented. Introduction to Patient Safety Slide 24 Notes Preventable adverse event (definition) This is a general definition of Situational Awareness Situational awareness is primarily achieved through routine information sharing among team members. Briefings are one method of updating. Information to be monitored includes patient status, staff fatigue status and workload, communication failures, direction of task assignment, poor documentation. Introduction to Patient Safety Slide 24 Notes Preventable adverse event (definition) This is a general definition of Situational Awareness Situational awareness is primarily achieved through routine information sharing among team members. Briefings are one method of updating. Information to be monitored includes patient status, staff fatigue status and workload, communication failures, direction of task assignment, poor documentation.

14. Risk management (definition) Clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself. Introduction to Patient Safety Slide 25 Notes Risk management (definition) Traditionally, risk management has been seen as a reactive function, i.e., addressing the impact of errors, adverse events, etc. However, in many settings, the risk management personnel conduct significant proactive, preventive activity.Introduction to Patient Safety Slide 25 Notes Risk management (definition) Traditionally, risk management has been seen as a reactive function, i.e., addressing the impact of errors, adverse events, etc. However, in many settings, the risk management personnel conduct significant proactive, preventive activity.

15. System error (definition) The delayed consequences of technical design or organizational issues and decisions. Introduction to Patient Safety Slide 26 Notes System error (definition) People working in complex settings have to develop processes (systems) to be efficient and productive, For example, patient identification A system cannot be designed to anticipate unusual circumstances (e.g., patients with names that are spelled differently, but sound identical) When individuals working in complex settings err, most often it is because the system �allowed� them to (e.g., no-alert that two patients with similar sounding names were being treated simultaneously)Introduction to Patient Safety Slide 26 Notes System error (definition) People working in complex settings have to develop processes (systems) to be efficient and productive, For example, patient identification A system cannot be designed to anticipate unusual circumstances (e.g., patients with names that are spelled differently, but sound identical) When individuals working in complex settings err, most often it is because the system �allowed� them to (e.g., no-alert that two patients with similar sounding names were being treated simultaneously)