2025 – PAGE 452 – PATIENT SAFETY AND QUALITY IMPROVEMENT
MEDICAL ERROR
Harm caused to the patient that results from the failure of a planned action to be completed as intended at the time of execution (for example, a nurse grabs the wrong medication and administers it), or the use of a wrong plan which results in the error (for example, a physician orders the wrong dose of a medication). Errors should be analyzed, and protocols should be put into place in order to limit confusion and limit the reliance on memory.
SENTINEL EVENT
The Joint Commission defines a sentinel event as an event that reaches a patient and results in death, permanent harm, severe temporary harm, or the risk therof. It is called a “sentinel” event because it signals “the need for immediate investigation and response.” Sentinel events are not related to harm or death related to the patient’s natural causes of illness. Sentinel events are not all due to medical errors, and not all medical errors are sentinel events. Think of medical errors as errors made by a mistake in action or judgement around the plan for a patient. For example, the wrong medication was given, or the wrong leg was amputated. These were sentinel events due to medical errors in which decisions made for a patient that were not in line with their interests or best practices. However, sentinel events can also include other events, such as a patient abduction, the suicide of a patient, or the discharge of a child to the wrong family.
PREVENTABLE ADVERSE EVENT
A preventable adverse event is a type of medical error that could have been prevented. For example, during an admission to the hospital, the family tells you that a child has a sulfa allergy. You admit the patient and prescribe a non-sulfa IV antibiotic. At discharge, the patient is prescribed a sulfa-containing antibiotic.
NON-PREVENTABLE ADVERSE EVENT
A non-preventable adverse event is related to the natural course of the patient’s illness, or due to an event that could not have been anticipated. For example, a patient receives steroids and then goes on to develop steroid psychosis.
NEAR MISS (AKA CLOSE CALL)
Potential adverse event, or error, that could have caused harm, but did not because of chance or because of some kind of intervention to prevent the error. Close calls and near misses provide opportunities for the healthcare team to develop preventative plans and actions.
PSYCHOLOGY OF CHANGE
Quality improvement involves change, and change is often not easy for individuals, teams, or organizations. There are MANY frameworks for facilitating change. Here are a few simple and intuitive points to keep in mind. People are more likely to accept change when:
- they are involved in making decisions
- they can see that the change is in their own best interest
- they believe in the goals of the change being pursued
- their peers also support the change
- their feedback is heard
- they are confident that they will be supported through any problems that come up because of the change (e.g., anxiety, overwork, financial pressures)
For the purposes of the exam, recognize the importance of the psychological dimension and the need to consider it in any plans for change. For example, suppose a question is about how a physician might introduce a new quality improvement initiative, such as a way to improve immunization rates.
Answers include:
- She should send out a memo to announce that the plan is taking effect next week.
- She should call a meeting where she will thank all the staff for their input into the new plan and ask for any final feedback before testing the plan.
Clearly, answer (b) addresses the psychological issues better than (a).