Exam 3 Flashcards
Safety?
prevention of health care errors and elimination/mitigation of patient injury
attributes of safety?
knowledge: principles and strategies
skills: technology and practice
attitudes
human factors science?
study of interrelationships among people, technology, and the work environment
acute care environment: complex
consider in/ability
focus on supporting providers and elminating hazards
high-reliability organizations? 5 characteristics?
manage environments with high risk
situational awareness: identify problems prediction and prevention avoid oversimplifying expertise > hierarchy commitment to reliance
6 measures of Braden scale (pressure sore risk)?
sensory perception moisture activity mobility nutrition friction/shear
culture of blame has transitioned to what?
process focus- WHAT went wrong?
good to prevent reoccurence.
characteristics of a culture of safety?
communication
mutual trust
positive safety culture
shared perceptions of safety
where is a health systems value? what is “just culture”?
reporting errors without punishment
balances need for remediation and need for discipline
skills exemplar?
medication administration: rights, supported, TALLman lettering, standardizing order sets
standardized med order?
generic name metric dose frequency route indication details
NOT part of standardized
volume # of tablets # of vials range of dose w/o objective measures
categories of errors? scope of errors?
diagnostic
treatment
preventative (monitoring, f/u, etc)
communication
latent and active
blunt and sharp diagram? exemplars of safety?
blunt: latent (organizational)
sharp: active (direct)
rights, BMV, TALLman, orders
levels of errors?
adverse: unintended by commission/omission- not disease
near miss: error of commission/omission that may have harmed patient- not by chance
sentinel: unexpected occurrence involving death/injury (must be reported)
sentinel event analysis?
root cause analysis
systems approach
ID of active and latent
multidisciplinary team
