Week 2 Post 1 Notes: Safety Checks and Bias

 

Medicine error notes

Sentinel event definition:

The Joint Commission defines a sentinel event as an unexpected occurrence involving death, serious physical or psychological injury. The event can result in death, permanent harm, or severe, temporary harm. The term sentinel refers to a system issue that may result in similar events in the future.

The patient safety officer is someone who has several functions such as coordinating patient safety protocols, updating staff for new procedures, and regularly assessing the efficiency of patient safety measures, aka makes sure everyone is safe

A root cause analysis: is how you find out what caused the problem, the first thing you should do is personal interviews, implement this as soon as there is a problem

Miscommunication causes the majority of issues because doctors are still human and don’t always communicate with one another

When looking for errors and making sure everything is safe the best thing to do is go to the floor where the work is happening, this is called rounding

Always ask questions when a problem is occurring and record it when legally required

Mistakes are very costly for both patient and hospital, patient can have even more medical problems, and the medical center can earn a bad reputation and people won’t come there for help anymore

Finding bias in an interview can be very hard and will require a lot of digging

Hospital has 45 days to conduct a Root Cause Analysis and implement corrective action to prevent another occurrence

Timeline maps are needed to conduct a root cause analysis or flow charts

 

Root cause is what the main thing that caused the problem is

Contributing factors are what helped cause the problems

Patient Safety officer conducts all of this and makes sure mistakes are investigated and fixed

Mistakes can happen at any time to anyone

Joint commission standards are used to evaluate medical centers and can also be used in law cases

Assumptions are dangerous