29. 3. Staff focus ■ Assess current safety culture
■ Identify the gap between current
culture and safety vision
■ Plan cultural interventions
■ Conduct periodic assessments of
culture
■ Celebrate examples of desired
behavior, for example, acknowledgment
of an error
4. Education and
training
■ Develop patient safety curriculum
■ Provide training and education of key
clinical and management leadership
■ Develop a core of people with patient
safety skills who can work across
microsystems as a resource
5.
Interdependence
of the care team
■ Build PDSA* cycles into debriefings
■ Use daily huddles to debrief and to
celebrate identifying errors *PDSA:
Plan, Do, Study, Act
33. Medicare Beneficiaries (Levinson, 2010) now estimate
that 180,000 deaths occur in hospitals per year in
people over 65 years of age. Without even including the
remainder of the population, this made medical errors
the third-leading cause of death after cardiovascular
disease and cancer.
Given this considerable excess mortality and harm, one
of the key foci of the field of patient safety is to
understand the underlying attributes, vulnerabilities, and
causes in the systems and processes of care leading to
errors and harm. If the mechanisms and causes are well
understood, interventions to address these can be
developed in order to prevent or mitigate harm.
When errors occur in high-risk environments, such as
health care (IOM, 2000), there is a greater potential for
harm. Health care is very complex, and an effective
system of classification should accurately represent this
level of complexity. By understanding human error, we
can plan for likely, and potentially predictable, error
scenarios and implement barriers to prevent or mitigate
the occurrence of potential errors. This chapter will
discuss the definitions, theories, and existing systems
of classification that are used improve our
understanding of the mechanisms of errors and patient
safety events in order to apply this knowledge to reduce
harm. Common definitions are essential to a
standardized classification system. See TABLE 10.1 for
some common definitions of some important terms in
the field of patient safety.
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36. A sentinel event is a Patient Safety Event that
reaches a patient and results in any of the
following:
■ Death
■ Permanent harm
■ Severe temporary harm and intervention
required to sustain life
(TJC, 2017).
Never
Events
National Quality Forum described 29 serious
events also called Serious Reportable Events,
“which are extremely rare medical errors that
should never happen to a patient.” (AHRQ,
2017b)
Incident “An unplanned, undesired event that hinders
completion of a task and may cause injury,
illness, or property damage or some
combination of all three in varying degrees from
minor to catastrophic. Unplanned and
undesired do not mean unable to prevent.
Unplanned and undesired also do not mean
unable to prepare for. Crisis planning is how we
prepare for serious incidents that occur that
require response for mitigation.” (Ferrante,
2017b)
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