20 Aug. 2010*

Medical Errors

20 Aug. 2010*

. ( ) . 20 Aug. 2010*

Cont. .2 : . .3 : .20 Aug. 2010*

Cont. . - . JAMA : . Barbara Starfield : . 20 Aug. 2010*

Cont. ( ). ( ) . 20 Aug. 2010*

: : : -1 . . 20 Aug. 2010*

Cont. -2 . . ( .(20 Aug. 2010*

Cont. 230 284 225 . - . . 20 Aug. 2010*

Cont. : .1 .2 . . : 4 18 . : 20 Aug. 2010*

20 Aug. 2010*

Cont. 20 30 ( ) .20 Aug. 2010*

Medical Errors statistics .1 IOM (Institute of medicine): 98-44 ( 195 ) 500 6/37 17 .2 6 .35 .410% . 20 Aug. 2010*

Cont. .513% . .5 .659% .:Adverse Events .7 70% Adverse Events . 6% Adverse Everts . 24% Adverse Everts . 8. 160 . 20 Aug. 2010*

Cont. ICU 16000 32000 . 8 .20 Aug. 2010*

Cont. 7000 Sloppy . 5/7 . 50.000 .42% . 20 Aug. 2010*

: 20 Aug. 2010*

Clossification Quality interagency coordination Task force (QUIC) 5 Schemes :20 Aug. 2010*

Cont.1- ( ......... )2- ( ... )3- Legal definitions ( ) ( negligenee malpractice ...) 4- ( ICU ...)5- ( ... ) 20 Aug. 2010*

Cont. : : . .20 Aug. 2010*

Cont. .20 Aug. 2010*

. 20 Aug. 2010*

Event (incidents) 1 - .2 - NHS : .3- 20 Aug. 2010*

Classifications 1- Errors2- Preventable Adverse3- Incident NO Harm4- Near Miss/close call/ potential Adverse Event 5- Hazard6- Harm7- Violtion

20 Aug. 2010*

Error.1 (Executive): .2 (Plan): Accident

20 Aug. 2010*

( ) Contributary Factors :.1 (CDP) Care Delivery Problems( ).2 (SDP)Service Delivey Pnoblems20 Aug. 2010*

Iufluencing Factors Causative Factors 20 Aug. 2010*

Iufluencing Factors . : .20 Aug. 2010*

Causative Factors : :1- .2- . Root Cause Analysis-(RCA)20 Aug. 2010*

1- Human Error2- knowledge-basad 3- : Role- based4- :Skill-base20 Aug. 2010*

Human Error .1 . .20 Aug. 2010*

.2Knowledge-based Errors . 20 Aug. 2010*

.3 Rule-based Errors 20 Aug. 2010*

.4 Skill-based Errors 20 Aug. 2010*

.1 Error of commision ( ) 20 Aug. 2010*

Cont..2 Error of omision ( ) (Hip Replacement)20 Aug. 2010*

Cont. omision commision .( 2 1)20 Aug. 2010*

1- Active Failures (Human-Machine interface) 2- Latent Errors20 Aug. 2010*

(Human-Machine interface) ActiveFailures1- .2- .3- (- ) 4- ((Sharp End Scalpet :

20 Aug. 2010*

Cont. ( ) : ( ) ( )

20 Aug. 2010*

Latent Errors ( ) ( Blunt Of Scalpel) .

20 Aug. 2010*

: :

20 Aug. 2010*

20 Aug. 2010*

Active Error Latent Error1- Sharp End Scapel ( ) Scapelt Blunt End2- 3- ( ) ( )4- ( ) ( ) ( )5- 6- ( )

Preventable Adverse Events : 20 Aug. 2010*

Adverse Event 1- Sentinel Event (Misadventure)2- No Harm Event 3- Near Miss

20 Aug. 2010*

Near- Miss /Close Call/ Potential Adverse Event . (Good Fortune Reasons) ( ) ( .) Recovery of Identification 20 Aug. 2010*

No Harm Event (No Actual Harm) . 20 Aug. 2010*

Sentinel Event (Misandventure) : (Death/Harm) .

20 Aug. 2010*

cognitive psychology of Task- oriented behavior.1 Error of Execution SlipSlapse.2 Error of planning 20 Aug. 2010*

Behavior.1 Attentional Behavior 2- Autopilot- Schematic B.))

20 Aug. 2010*

MistakeDefinitions Attentional 20 Aug. 2010*

Cont.Reasons: ( ) : 1- 2- ( )20 Aug. 2010*

Slips / Slapse : Schematic Executive Slips Slapses 20 Aug. 2010*

Examples (Slips ) ( ) (Slips ) (Slapses )

20 Aug. 2010*

20 Aug. 2010*

Slips (visible) / Slapses (non-visible)Mistaks Base :Autopilot, Automatic, Schematic Executive) ( Attentional , Plan Solving Problem Risk factors (Emotional) (Sensort) -1- ( ) -2 ( ) ( ) ( ...) ...1- 2-

Violation ( ) Short cut :1- Reasoned V.2- Reckless V.3- Malicious V.

20 Aug. 2010*

Cont. Reasoned V. Reckless V. Malicious V. Acts OF Sabotage

20 Aug. 2010*

: Underuse Overuse ( ) Misuse20 Aug. 2010*

Underuse :1- 1.1 21. 31. ( Screening)2- 2. 22.

20 Aug. 2010*

(Overuse) :1- : 2- (Paraclinic)3-

20 Aug. 2010*

: Misuse : 1- ( Rash )2- ( )20 Aug. 2010*

Root Cause Analysis* : . [1] Person Approach [2] System Approach . : 20 Aug. 2010*

1- Personal Approach .1 . 2. ( ) . .3 .4 . .20 Aug. 2010*

Cont. .5 .6 . 20 Aug. 2010*

( ...) . .20 Aug. 2010*

. . .20 Aug. 2010*

. . ( ...) . . 20 Aug. 2010*

Cont. . .20 Aug. 2010*

2- : System Approach . . .20 Aug. 2010*

Swiss Cheese Model James Reason . : . . ( ) .

20 Aug. 2010*

Cont. . :1- 2- ( )

20 Aug. 2010*

No single barrier is foolproof () ( ) . : ( ) 20 Aug. 2010*

Cont. :1- . 2- . 3- () Hang it Backward4- ( )5- 20 Aug. 2010*

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Important .20 Aug. 2010*

* Root Cause Analysis ( ...) . . .20 Aug. 2010*

RCA . . .20 Aug. 2010*

1- Organization Factors . .20 Aug. 2010*

2- Technical Factors .20 Aug. 2010*

3- Human Factors . Cognitive . . Automatic Solving Problem . 20 Aug. 2010*

Automatic, Autopilot : . .20 Aug. 2010*

Cont. Executive Slips Slapses . ... . .20 Aug. 2010*

Solving Problem . . Plan Mistake . 20 Aug. 2010*

Cont. : ( )20 Aug. 2010*

20 Aug. 2010*

:1- ( )2- Specialization Fragmentation . 3- over work burnout20 Aug. 2010*

Cont.4- ( )5 Intravenous Pump ( )6- : . . 7- : .20 Aug. 2010*

Cont..8 .9 .10 .11 ( ).12

20 Aug. 2010*

. : 20 Aug. 2010*

Cont.1 . .20 Aug. 2010*

Cont.2 . . 20 Aug. 2010*

Cont.3 . 20 Aug. 2010*

Cont.4 : ... : ... 20 Aug. 2010*

Cont. : : : ... . . 20 Aug. 2010*

Cont.5 ( ...) 6 ( ) . 20 Aug. 2010*

Cont.7 .8 : . 20 Aug. 2010*

Cont.9 : ... 10 ! : ! 20 Aug. 2010*

Never Events National Quality forum 28 .They are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability."The 28 Never Events are:20 Aug. 2010*

Cont.A recent Leapfrog Group Study finds that roughly half of the 1,285 hospitals that responded to their survey waive fees for never events, and that hospitals that do waive fees are much more likely to have perfect scores on the Leapfrog Safe Practices Score survey.20 Aug. 2010*

) 1. Surgery performed on the wrong body part2. Surgery performed on the wrong patient3. Wrong surgical procedure performed on a patient4. Unintended retention of a foreign object in a patient after surgery or other procedure20 Aug. 2010*

Cont.6. Intraoperative or immediately post-operative death in an ASA Class I patient7. ( ) Artificial insemination with the wrong donor sperm or donor egg20 Aug. 2010*

) 1- Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility2- . Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended3- Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility20 Aug. 2010*

) 1- Infant discharged to the wrong person2- ) 4 Patient death or serious disability ( associated with patient elopement (disappearance)3- Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility20 Aug. 2010*

) 1- Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)2- ( ) Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products3- Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility20 Aug. 2010*

Cont.4- . Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility5- ( Kernicterus ) Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates6- 3 4 Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility7- manipulative Patient death or serious disability due to spinal manipulative therapy20 Aug. 2010*

) 1- Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility2- Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances3- Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility20 Aug. 2010*

Cont.4- Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility5. Patient death or serious disability associated with a fall while being cared for in a healthcare facility20 Aug. 2010*

) 1- Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider2- Sexual assault on a patient within or on the grounds of the healthcare facility3- Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility4. Abduction of a patient of any age20 Aug. 2010*

Four ActionsThe Leapfrog Group offers four actions as industry standards following a never event: 1)apologize to the patient, 2) report the event, 3) perform a root cause analysis, and 4) waive costs directly related to the event.20 Aug. 2010*

5 ( )Five Steps to Safer Health Care1- . . Speak up if you have questions or concerns. 2- Keep a list of all the medicines you take. . 3- . Make sure you get the results of any test or procedure.4- . Talk with your doctor and health care team about your options (choices) if you need hospital care. 5- . 5. Make sure you understand what will happen if you need surgery.20 Aug. 2010*

1- ( 96% 4% ) ( ) 2- 3- 20 Aug. 2010*

Cont. : ... 20 Aug. 2010*

. . . . 20 Aug. 2010*

Cont. . . . 20 Aug. 2010*

. : ) ) ) ( .) ) . 20 Aug. 2010*

: . . . .20 Aug. 2010*

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