Culture

Question 1

What is the first element of an ideal safety culture?

Answer 1

Collect, analyze, share safety information

Question 2

What is the second element of an ideal safety culture

Answer 2

Error reporting and feedback loops (front line engaged); sensitivity to errors

Question 3

What is the third element in an ideal safety culture

Answer 3

Fair and just response to errors

Question 4

What is the fourth element of an ideal safety culture

Answer 4

Flexibility to restructure when necessary, defer to expertise, reduce hierarchy

Question 5

What is the fifth element an ideal safety culture

Answer 5

Willingness to learn from errors

Question 6

Culture: local or organizational?

Answer 6

Local unit level culture as focus of evaluation and action

Question 7

What are 2 high focus areas when interpreting and responding to safety culture survey data

Answer 7

Teamwork and communication

Question 8

What is the typical threshold and survey response rates

Answer 8

60%

Question 9

Should you identify disseminate best practices from high performing work units based on survey results

Answer 9

Yes

Question 10

What does high level of voluntary reporting of near Mrs. suggest of a culture?

Answer 10

A culture is advanced enough that Frontline understand what makes a defect system failure even if it doesn’t reach the patient

Question 11

What are other ways to back up voluntary reporting

Answer 11

Observations and technology

Question 12

Does leadership active involvement in prioritizing patient safety suggest a strong culture

Answer 12

Yes

Question 13

What are three groups that should be involved in patient safety initiatives

Answer 13

Leadership, multidisciplinary engagement, patient and family involvement

Question 14

What is a example of standardization

Answer 14

Color coded wristbands that reduce errors within departments across organizations and throughout the industry

Question 15

What are checklists?

Answer 15

List of actions that should be performed to optimize patient outcomes

Question 16

What are examples of checklists?

Answer 16

Surgical safety checklist, handoffs, Keystone ICU project

Question 17

Should you personalize or you storytelling in error reporting a near miss education?

Answer 17

Yes

Question 18

What is the science of human factors the study of

Answer 18

The inter-relationship between humans, the tools and equipment they use in the workplace, and the environment in which they work

Question 19

What are the six elements of a high performing team?

Answer 19

Team structure, leadership, communication, situation monitoring, mutual support, coordination and collaboration.

Question 20

What are three barriers to disclosure of unexpected outcomes

Answer 20

Like a culture of safety, psychological barriers, legal barriers.

Question 21

What is the term that provides the patient family with all of the information needed for appropriate care decisions?

Answer 21

Effective disclosure

Question 22

What are six process steps for the conversation to patient/family?

Answer 22

Designated personnel roles, conversation outlines, special communication needs accommodations, support services, steps for follow-up conversations, and documentation

Question 23

What are five things that the lack of health literacy leads to?

Answer 23

Readmissions, and ability to navigate the healthcare spectrum, increased health cost, limited preventative medicine, self report of poor health

Question 24

What is the belief that no one will be punished or humiliated for speaking up with ideas questions concerns or mistakes?

Answer 24

Psychological safety

Question 25

Building psychological safety requires what?

Answer 25

Softening of authority gradients

Question 26

The single greatest impediment to air prevention in the medical industry is?

Answer 26

We punish people for making mistakes

Question 27

What are three key facts about human error

Answer 27

Cannot be eradicated, error is part of the human condition, we must learn from errors

Question 28

How can consequences of errors be mitigated?

Answer 28

Anticipate predictable errors, build safe processes, enhance communication skills and teamwork

Question 29

Managing at risk behavior requires what two things?

Answer 29

Feedback and coaching

Question 30

What is one thing reckless behavior requires?

Answer 30

Administrative consequence

Question 31

What is the organizational accountable for in a just culture?

Answer 31

Designing safe systems that encourages and supports safe choices of staff

Question 32

What are clinicians and staff accountable for in a just culture?

Answer 32

Accountable for the quality of their choices. 

Question 33

Define just culture

Answer 33

Don’t simply punish people because of their actions, but always hold them accountable for their decisions

Question 34

The cognitive process of automatic processing leads to what?

Answer 34

Slips and lapses, errors of execution

Question 35

What are examples of errors of execution

Answer 35

Interruptions, fatigue, time pressure, anger, anxiety, fear, boredom

Question 36

What is right plan/intention, but do it wrong called?

Answer 36

Error of execution

Question 37

What is intended action/plan but not the correct one called?

Answer 37

Errors of planning

Question 38

Conscious processing (problem solving) leads to what?

Answer 38

Mistakes – errors are planning

Question 39

Behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified is called what?

Answer 39

At risk behavior

Question 40

What are three justifications for at risk behavior?

Answer 40

Normalized defiance, workaround, drift

Question 41

What are two common at risk behavior failures?

Answer 41

Hand hygiene and two patient identifiers

Question 42

What three concepts creates incentive to do at risk behavior?

Answer 42

Consequences are weaker than the rules, consequences are uncertain, consequences are delayed or not apparent.

Question 43

What is the conscious behavioral choice to disregard a substantial and unjustifiable risk such as a rule procedure law or policy?

Answer 43

Reckless behavior

Question 44

What is no intention to cause harm

Answer 44

Reckless behavior

Question 45

Which behavioral choice has a need to adjust to highly variable conditions, and is comfortable with inherit risk/threats?

Answer 45

Drift

Question 46

When team members make choices to go against policy to become more efficient, it is called what?

Answer 46

Workarounds

Question 47

Why Should you consider other inputs before defining actions based on the survey results?

Answer 47

Because culture is multi factorial

Question 48

You’rreducation clinical managers in your healthcare facility on how to identify appropriate events for a RCA. Whixh event provides the best opportunity for an RCA?

Answer 48

Biopsy samples from my colonoscopy or never received by pathology after the procedure

Question 49

Should you ask the nurse what was occurring at the time and why she chose to bypass the policy when she did not comply with the BCMA? 

Answer 49

Yes

Question 50

If a surgeon leaves the hospital to catch a flight before the surgery is finished and the x-ray reveals a retained instrument what should leadership do next?

Answer 50

Counsel the surgeon about clinical standards using appropriate accountability system