BHP II

Question 1

simple definition of error?

Answer 1

dong the wrong thing when meaning to do the right thing - Runciman

Question 2

Adverse Event ?

Answer 2

An injury caused by medical management rather than underlying condition of the patient

Question 3

Violation?

Answer 3

A deliberate deviation from an accepted protocol or standard of care

Question 4

Errors terbagi 2 yaitu

Answer 4

Skill-based slips and lapses

Mistakes

Question 5

Skill-based and lapses error terbagi 2

Answer 5

• Attentional slips of action

- Lapses of memory

Question 6

Mistakes terbagi 2

Answer 6

• Rule based mistakes

- Knowledge based mistakes

Question 7

Situations associated with an increased risk of error

Answer 7

CUTI PH

• inadequate checking
• unfamiliarity with the task
• Shortage of time
• Inexperience
• Poor procedure
• poor human equipment

Question 8

Individual factors that presdispose to error

Answer 8

• Limited memory capacity
• Further reduced by: fatugue, stress, hunger, illness, language/cultrual factors, hazardous attitudes
• HALT (hungry, Angry, Late, Tired)

Question 9

A performance-shaping factors

Answer 9

IM SAFE
Illness
Medication
Stress
Alcohol
Fatigue
Emotion

Question 10

Incident monitoring is..

Answer 10

-involves collecting and analysing information about any events that could have harmed or did harm anyone in the organization (KUMPULKAN INFORMASI YG DPT MEMBAHAYAKAN)

Question 11

Culture: a workable definition

Answer 11

Shared values (what is important) and beliefs (how things work) that interact with an organization’s structure and control system to produce behavioural norms (the way we do things around here)

Question 12

Incident reporting and monitoring strategies

Answer 12

others include
-anonymous reporting
- timely feedback
- open acknowledgement of successes resulting from incident reporting
-reporting of near misses
. “free lessons” can be learned
. system improvements can be instituted as a result of the investigation but at no “cost” to a patient

Question 13

RCA model, a Rigorous, Confidential Approach to answering…

Answer 13

• What happened?
• Why did it happen
• What are we going to do to prevent it from happening again
• How will we know that our actions improved patient safety?

Question 14

RCA model focus on..

Answer 14

• prevention, not blame or punishment

- system level vulnerabilities other than individual performances

Question 15

Personal error reduction strategies

Answer 15

• know yourself
• know your environment
• know your task
• preparation and planning
• build “checks” into your routine
• Ask if you don’t know

Question 16

Mental preparedness

Answer 16

• assume that errors can and will occur
• identify those circumstances most likely to breed error
• have contingencies in place to cope with problems, interruptions and distructions
• mentally rehearse complex procedures

Question 17

Why is medicine so suspectible?

Answer 17

• Lack of awareness to the problem
- “Culture of Silence”
Blame and shame mentality •

• System constrain – – – –
  Staffing problems
  Fatigue
  Knowledge requirements Communication and continuity of care

Question 18

Medical negligence is.

Answer 18

Failure to meet the standard of practice of an average qualified physician practicing in the specialty in question

occurs merely when there is an error but when the degree of error exceeds the accepted norm

Question 19

Reasons why people sue their doctors

Answer 19

Advised to sue by influential other
Needed money
Believed there was a cover
Child would have no future
Needed information 
Wanted revenge, license