lect 3 and 4 b

Question 1

Quality Management System

Answer 1

a set of interrelated or
interacting elements that organizations use to formulate quality
policies and quality objectives and to establish the processes
that are needed to ensure that policies are followed and
objectives are achieved.

Question 2

Quality Management System includes

Answer 2

tructures,
programs, practices, procedures, plans, rules, roles,
responsibilities, relationships, contracts, agreements,
documents, records, methods, tools, techniques, technologies,
and resources.

Question 3

Quality Framework

Answer 3

The Quality Framework confirms an organisations commitment to quality and
describes the organisations approach to quality.

Question 4

Quality Framework includes

Answer 4

• Describes the Quality Policy
• States the desired outcomes
• Describes individual responsibility for ensuring Quality;
• Supports the Organisations Strategic Direction & Plan
• Ensures the Organisation achieves and maintains a low risk status from the
perspective of regulatory bodies due to planned monitoring, maintenance and
improvement of quality
• Promotes Policies, Procedures, Guidelines, Manuals and Forms.

Question 5

Clinical Quality Registries

Answer 5

Clinical quality
registries are
organisations which
systematically monitor
the quality
(appropriateness and
effectiveness) of health
care, within specific
clinical domains, by
routinely collecting,
analysing and reporting
health-related
information.

Question 6

Elements of a Culture of Safety

Answer 6

Human Factors
• Open Communication
• Accountability
• Professional Accountability – Speaking Up for Safety
• A Just Environment
• Safety Design
• All healthcare workers involvement

Question 7

Promoting Professionalism and Accountability Programme elements

Answer 7

1. Leaders’ commitment
2. Leading reliability
3. Difficult conversations
4. Open disclosure
5. Performance management
6. Speaking up

Question 8

Graded assertiveness

Answer 8

It is a process of communicating, advocating and directing in stressful or crisis scenarios, learned skill

Question 9

C – U – S – S

Answer 9

Cuss is a technique that uses a graded
assertiveness approach to communicating.
Should someone be concerned with a
process or intervention being put in place,
they can raise concerns, getting more
assertive if their concerns aren’t listened
to.
Concern
Uncomfortable
unSafe
Stop

Question 10

PACE consists

Answer 10

Probe
Alert
Challenge
Emergency

Question 11

The Perfection Myth

Answer 11

if we try hard enough we

will not make any errors

Question 12

The Punishment Myth

Answer 12

if we punish people when
they make errors they
will make fewer of them

Question 13

Individual factors that predispose to error

Answer 13

limited memory capacity
• further reduced by:
○ fatigue
○ stress
○ hunger
○ illness
○ language or cultural factors
○ hazardous attitudes

Question 14

Error Types

Answer 14

Intended actions

Unintended actions

Question 15

intended actions

Answer 15

Routine violations
Reasoned violations
Reckless violations 
Malicious violations
Rule based mistakes 
Knowledge based mistakes

Question 16

Routine violations

Answer 16

regular short-cuts in tasks made for convenience. They are accepted by the clinical team,
and sometimes by management, normally because the procedure is badly designed.

Question 17

Reasoned violations

Answer 17

occasional changes in procedure for good reason and with good intent. It may be an
emergency or unusual situation. The change should be discussed beforehand wherever possible and always
documented afterwards.

Question 18

Reckless violations

Answer 18

unacceptable changes in procedure. Harm is likely but not intended. There is an active
lack of care.

Question 19

Malicious violations

Answer 19

• deliberate acts that are intended to cause harm or damage. They are unusual but the
  outcome is likely to be very serious

Question 20

Rule based mistakes

Answer 20

made by people undertaking tasks with some knowledge of the rules and with good
intent, but they choose the wrong solution for the problem

Question 21

Knowledge based mistakes

Answer 21

made by people undertaking new tasks with good intent but their limited
knowledge results in a mistake. They don’t know that they don’t know.

Question 22

Unintended actions

Answer 22

Lapses

Slips

Question 23

Lapses

Answer 23

errors made by experienced people undertaking familiar tasks with very little conscious thought.
They forget something routine when they are not concentrating on the task or when they are interrupted

Question 24

Slips

Answer 24

errors made by experienced people undertaking any task. There is a slip in the action [such as dropping
an instrument] which could happen to anyone, however experienced.