Final Exam Review Flashcards
Comprehensive - Ch. 1-4, 8-11, 14-17, 21-22
Active Failures (Ch. 8)
Errors and violation caused by acts performed by workers (e.g. nurses) closest to the sharp end of the system (e.g. patient care) that impact system safety most directly (Reason, 1997).
Adverse Events (Ch. 8)
Untoward incidents, therapeutic misadventures, iatrogenic injuries, or other adverse occurrences directly associated with care or services provided within the jurisdiction of a medical center, outpatient clinic, or other facility.
Blunt End (Ch. 8)
Levels of strategic and other top-level decision-making persons or groups in an organization that impact the work at the point of care delivery (the sharp end).
Cognitive Task Analysis (Ch. 8)
A technique for interview data collection and analysis to describe the cognitive work and influencing factors surrounding situations that led to and resulted in decisions.
Complex Systems (Ch. 8)
Systems in which work includes both cognitive and physical demands and is characterized by dynamism, large numbers of parts and connectedness between parts, high uncertainty, and risk.
Fixation (Ch. 8)
Failure to revise the assessment of a situation as new information becomes available.
Gaps (Ch. 8)
Another term for latent conditions or error-producing factors.
Hindsight Bias (Ch. 8)
The natural tendency for humans looking back from an accident to consistently overstate what could have been anticipated in foresight and to see only a simplified path of decision making related to the specific accident.
Human Factors (Ch. 8)
Sets of human-specific physical, mental, and behavioral properties, as well as the science of how people interact with tasks, machines (or computers), and the environment with the consideration that humans have properties that demonstrate limitations and capabilities.
Latent Conditions (Ch. 8)
Error-producing factors like poor design, gaps in supervision, undetected system failures, lack of training, and the like arising from the decision-making levels (blunt end) of organizations that combine with active failures to result in adverse events.
Layers of Defense (Ch. 8)
Organizational safeguards in place to prevent anticipated injury, damage, or failure.
Loss of Situation Awareness (Ch. 8)
Failure to maintain accurate tracking of the multiple and changing interactions between parts of processes or systems.
Medical Error (Ch. 8)
Failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim.
Mindfulness (Ch. 8)
The ability to scrutinize and refine expectations based on new information and/or contextual aspects of a situation.
Mistakes (Ch. 8)
Planning failures–“deficiencies or failures in the judgmental and/or inferential processes involved in the selection of an object or in the specification of the means to achieve it.”
Near-Miss Event (Ch. 8)
Any process variation that did not affect the outcome in a given event, but for which a recurrence carries a significant chance of a serious adverse outcome.
New Look (Ch. 8)
An approach to patient safety based on understanding and adaptation of the evolution of failure, as described by James Reason.
Patient Safety (Ch. 8)
Freedom from accidental injury.
Reporting System (Ch. 8)
A safety information system that collects, analyzes, and disseminates information about near misses, adverse events, and safety systems.
Safety Culture (Ch. 8)
Shared values and beliefs in an organization that interact with the organizational structures and systems and produce behavioral norms surrounding work.
Sense-making (Ch. 8)
The ability to reconstruct and interpret incoming information anew in ambiguous, complex, and evolving situations.
Sharp End (Ch. 8)
Frontline personnel at the operations point of the organization; for example, at the point of patient care in a healthcare organization.
Slips and Lapses (Ch. 8)
Execution failures or “errors which result from some failure in the execution and/or storage of an action sequence, regardless of whether or not the plan which guided them was adequate to achieve its objective.”
Stacking (Ch. 8)
The cognitive process of maintaining a work-to-be-done activities list, and the organizing and reprioritizing of activities as situations in care or workflow evolve.
Trade-Offs (Ch. 8)
Decision resolutions that involve conflicting choices between highly unlikely but highly undesirable events and highly likely but less catastrophic ones.
