Patient Safety
What safety content the exam tests
Patient safety rests on systems thinking: errors are consequences of design, not bad people. Know Reason's Swiss cheese model (latent conditions and active failures), the person versus system approach, and error types: slips, lapses, mistakes, and violations. Know high-reliability principles: preoccupation with failure, reluctance to simplify, sensitivity to operations, resilience, and deference to expertise. Just culture and psychological safety determine whether staff report at all.
Know the reporting and learning infrastructure: voluntary event reports including near misses, trigger tools, and the definitions of adverse event, sentinel event (unexpected death, serious harm, or risk thereof), and never event. RCA must be timely, interdisciplinary, and systems-focused; RCA squared emphasizes action plans with owners and measurement. FMEA anticipates failure before it occurs.
Operationally, review handoffs (SBAR), TeamSTEPPS communication, medication safety (high-alert drugs, look-alike/sound-alike names, reconciliation), healthcare-associated infections, falls, pressure injuries, alarm fatigue, surgical safety checklists, and National Patient Safety Goals. Include disclosure to patients and support for second victims.
Traps
- Assuming every adverse event is a sentinel event, or narrowing the definition too far.
- Choosing to counsel an employee when the fix is a forcing function or redesign.
- Believing low report counts mean a safe unit; often they signal fear.
Rule of thumb
Ask whether a competent person doing the task as designed could fail here. If yes, redesign the system. Worked example: two look-alike insulin vials are swapped. Retraining the nurse addresses one person; separate storage, barcode scanning, and independent double-checks address the design flaw.