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Patient safety > Reporting > Flashcards

Reporting Flashcards

1
Q

Number one contributing factor for sentinel events

A

Communication failure

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2
Q

Signal of safety culture that is a proactive opportunity to improve before significant event occurs

A

Near miss reporting

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3
Q

What was designed to improve patient safety through analysis of reporter events and reduction or elimination of the risks and hazards associated with the delivery of patient care

A

The patient safety and quality improvement act of 2005

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4
Q

What are the roles of learning boards?

A
  1. Provide space to share defects
  2. Promote visibility of threats and missteps
  3. Show resolution of defects
  4. Promote threat awareness and reporting behaviors to enhance a culture of safety
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5
Q

Proactive vs reactive risk assessment

A

Proactive - failure modes and effects analysis (fmea)

Reactive - root cause analysis (rca)

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6
Q

What are the two characteristics of a good rca?

A

Thorough and Credible

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7
Q

Describe pitfalls of bundles vs check lists

A

Bundles- not check lists and are all or nothing

Checklist- done out of order, no buy in, lack of ownership

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8
Q

What percentage of medication errors have an HIT component

A

25%

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9
Q

What are the components of a risk priority number (rpn)

A

Severity 1-5 5 is bad (worst possible outcome)

Detect ability 1-5 5 is bad(detection not possible before reaching patient)

Frequency 1-5 increasing frequency

Controls 1 3 5 (does the control work? 5 =no)

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10
Q

What represents science at the intersection of psychology and engineering looking at all aspects of a work system to support human performance and safety.

A

Human Factors Analysis

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11
Q

What are the components of systems that determine safety?

A 
People
Tasks
Tools/technology
Environment
Organization
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12
Q

What are the 3 steps in the design strategy?

A
  1. Standardize and simplify
  2. Application of controls
  3. Catch errors and mitigate harm
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13
Q

What are the five principles of high reliability organizations with examples

A
  1. Sensitivity to operations - heightened awareness of the state of relevant systems and processes
  2. Reluctance to simplify- the work is complex and there is potential to fail
  3. Preoccupation with failure - view near misses as opportunities to improve rather than proof of success
  4. Deference to expertise- value expertise over seniority
  5. Practicing resilience- prioritize emergency training for many unlikely but possible failures
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14
Q

What are the components of crew resource management?

A 
Leadership
Co-operation
Situation awareness
Decision making
Communication
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15
Q

Link the diagrams/charts to what they illustrate:

Fishbone diagram
Control chart
Spaghetti chart
Pareto diagram

A

Fishbone = root cause analysis/ cause and effect

Control chart = similar to run chart. Shows trends over time in relation to quality improvement

Spaghetti chart = part or lean to show workflows and redundancies

Pareto = shows frequency of defects and their cumulative impact.

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16
Q

What best demonstrates non random process variation over time?

A

Control chart—- step up from run chart as it had upper and lower control limits to measure usual and unusual variation.

17
Q

What bias accepts a diagnosis before it has been fully verified accounting for high proportion of missed diagnosis

A

Premature closure

18
Q

What is anchoring bias?

A

Over reliant on the first piece of information they hear.

19
Q

What is the availability heuristic?

A

Overestimate the importance of information that is available to them.

20
Q

Name the four tests to determine culpability

A
  1. Deliberate?
  2. Incapacity?
  3. Foresight? Related to short cuts
  4. Substitution test? Could someone else placed in same position have made same error. If so error is blameless
21
Q

Describe the following errors:

Active vs latent
Omission vs comission

A

Active- errors and violations having immediate neg results. Caused by indiv

Latent- caused by circumstances of the system. Caused by org

Omission - not doing something you should have done

Commission- doing something you should not have done

22
Q

What does a balance measure do?

A

Fixes one issue and causes another

Patient safety (1 decks)

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