Culture Flashcards
What is the first element of an ideal safety culture?
Collect, analyze, share safety information
What is the second element of an ideal safety culture
Error reporting and feedback loops (front line engaged); sensitivity to errors
What is the third element in an ideal safety culture
Fair and just response to errors
What is the fourth element of an ideal safety culture
Flexibility to restructure when necessary, defer to expertise, reduce hierarchy
What is the fifth element an ideal safety culture
Willingness to learn from errors
Culture: local or organizational?
Local unit level culture as focus of evaluation and action
What are 2 high focus areas when interpreting and responding to safety culture survey data
Teamwork and communication
What is the typical threshold and survey response rates
60%
Should you identify disseminate best practices from high performing work units based on survey results
Yes
What does high level of voluntary reporting of near Mrs. suggest of a culture?
A culture is advanced enough that Frontline understand what makes a defect system failure even if it doesn’t reach the patient
What are other ways to back up voluntary reporting
Observations and technology
Does leadership active involvement in prioritizing patient safety suggest a strong culture
Yes
What are three groups that should be involved in patient safety initiatives
Leadership, multidisciplinary engagement, patient and family involvement
What is a example of standardization
Color coded wristbands that reduce errors within departments across organizations and throughout the industry
What are checklists?
List of actions that should be performed to optimize patient outcomes
What are examples of checklists?
Surgical safety checklist, handoffs, Keystone ICU project
Should you personalize or you storytelling in error reporting a near miss education?
Yes
What is the science of human factors the study of
The inter-relationship between humans, the tools and equipment they use in the workplace, and the environment in which they work
What are the six elements of a high performing team?
Team structure, leadership, communication, situation monitoring, mutual support, coordination and collaboration.
What are three barriers to disclosure of unexpected outcomes
Like a culture of safety, psychological barriers, legal barriers.
What is the term that provides the patient family with all of the information needed for appropriate care decisions?
Effective disclosure
What are six process steps for the conversation to patient/family?
Designated personnel roles, conversation outlines, special communication needs accommodations, support services, steps for follow-up conversations, and documentation
What are five things that the lack of health literacy leads to?
Readmissions, and ability to navigate the healthcare spectrum, increased health cost, limited preventative medicine, self report of poor health
What is the belief that no one will be punished or humiliated for speaking up with ideas questions concerns or mistakes?
Psychological safety
Building psychological safety requires what?
Softening of authority gradients
The single greatest impediment to air prevention in the medical industry is?
We punish people for making mistakes
What are three key facts about human error
Cannot be eradicated, error is part of the human condition, we must learn from errors
How can consequences of errors be mitigated?
Anticipate predictable errors, build safe processes, enhance communication skills and teamwork
Managing at risk behavior requires what two things?
Feedback and coaching
What is one thing reckless behavior requires?
Administrative consequence
What is the organizational accountable for in a just culture?
Designing safe systems that encourages and supports safe choices of staff
What are clinicians and staff accountable for in a just culture?
Accountable for the quality of their choices. 
Define just culture
Don’t simply punish people because of their actions, but always hold them accountable for their decisions
The cognitive process of automatic processing leads to what?
Slips and lapses, errors of execution
What are examples of errors of execution
Interruptions, fatigue, time pressure, anger, anxiety, fear, boredom
What is right plan/intention, but do it wrong called?
Error of execution
What is intended action/plan but not the correct one called?
Errors of planning
Conscious processing (problem solving) leads to what?
Mistakes – errors are planning
Behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified is called what?
At risk behavior
What are three justifications for at risk behavior?
Normalized defiance, workaround, drift
What are two common at risk behavior failures?
Hand hygiene and two patient identifiers
What three concepts creates incentive to do at risk behavior?
Consequences are weaker than the rules, consequences are uncertain, consequences are delayed or not apparent.
What is the conscious behavioral choice to disregard a substantial and unjustifiable risk such as a rule procedure law or policy?
Reckless behavior
What is no intention to cause harm
Reckless behavior
Which behavioral choice has a need to adjust to highly variable conditions, and is comfortable with inherit risk/threats?
Drift
When team members make choices to go against policy to become more efficient, it is called what?
Workarounds
Why Should you consider other inputs before defining actions based on the survey results?
Because culture is multi factorial
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?
Biopsy samples from my colonoscopy or never received by pathology after the procedure
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? 
Yes
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?
Counsel the surgeon about clinical standards using appropriate accountability system
