Quantum Units Education®

Introduction

1. While some refer to medical error as any act, or failure to act, which results in harm to a patient, others refer to medical error as any action within the process of care that may have the potential to cause harm.

2. An examination of case studies of errors presented in the Annals of Internal Medicine suggest that a single error does not guarantee that a patient will experience a medical injury, but rather as many as 11 separate individual errors may occur before a patient is actually harmed.

Dimensions of Medical Errors

3. The most common types of preventable errors resulting in adverse events have been identified as:

4. A recent report suggests the most lethal patient safety incidents, or those most closely associated with mortality, include failure to rescue and unexpected death during a low-risk hospitalization.

5. According to the A-B-C model that is the foundation of most behavior based interventions, an _________ is a stimulus that precedes a behavior and encourages performance of that behavior.

Organizational Applications for Large-Scale Change

6. Organizational behavioral management (OBM) provides an approach to healthcare which strategically integrates rationalism and reinforcement in the design of interventions to benefit patient safety.

OBM Interventions to Address Medical Errors

7. The overarching theme of the OBM intervention approach is to reduce the probability of error by increasing the frequency of safe standards of practice.

System-Change Participation

8. Much of the patient safety literature calls for improved incident reporting systems that include less focus on finding fault and:

9. Peer-to-peer observational methods may be used to help reduce diagnostic errors among professionals, while peer-to-peer coaching can ensure compliance with recommended practices and offer opportunities for corrective feedback when dealing with treatment errors.

10. A major type of communication error affected by multiple factors, including staffing shortages and caregiver fatigue is: