safety

• Safety is freedom from accidental injuries; ensuring patient safety involved the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur
• safe care is avoiding injuries to patients from the care that is intended to help them, involves making evidence-based clinical decisions to maximise the health outcomes of an individual to minimize the potential for harm
• levels of error

  • adverse event - an event that results in unintended harm to the patient by an act of commission of omission rather than by the underlying disease or condition of the patient
  • near miss - error of commission or omission that could have harmed a patient, but harm did not occur as a result of chance
  • sentinel event - unexpected occurrence involving death or serious injury
• categories of errors

  • diagnostic
  • treatment
  • preventive
  • communication
• placement of errors

  • latent
  • active
• foundational domains for error prevention:

  • health care culture
  • learning systems
• human factors framework

  • human factors consider the ability or inability to perform exacting tasks while attending to multiple things at once, human factors offer a systematic approach to studying process and outcome effectiveness for greater error prevention and greater efficiency
• crew resource management: emphasizes the role of human factors in high stress, high risk work environment, used to improve team functioning in operating rooms, emergency departments, labor and delivery, and perioperative areas
• high reliability organizations: manage work that involves hazardous environments, characteristics of the HRO mindset, sensitivity to operations, focused on predicting and preventing rather than reacting to errors, reluctance to simplify, deference to epxertise