Giddens: Safety

Question 1

IOM

Answer 1

Institute of Medicine

Question 2

Safety

Answer 2

freedom from accidental injury

Question 3

safe care

Answer 3

avoiding injuries to patients from the care that is intended to help

Question 4

NPSF

Answer 4

the National Patient Safety Foundation

Question 5

patient safety

Answer 5

prevention of health care errors, and elimination/mitigation of pt injury

Question 6

commission errors

Answer 6

doing the wrong thing

Question 7

omission errors

Answer 7

not doing the right thing (omitting the right thing)

Question 8

execution

Answer 8

doing the right thing incorrectly

Question 9

QSEN

Answer 9

quality and safety for nurses

Question 10

safety- qsen

Answer 10

minimizes risk of harm to pt and providers through both system effectiveness and individual performance

Question 11

adverse event error

Answer 11

An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient

Question 12

near miss error

Answer 12

An error or commission or omission that could have harmed the patient, but serious harm did not occur

Question 13

the patient received a contraindicated drug but did not experience an adverse drug reaction

Answer 13

example of a chance: near miss error

Question 14

a potentially lethal overdose was prescribed, but a nurse identified the error before administering the medication

Answer 14

example of a prevention; near miss error

Question 15

a lethal dose overdose was administered but discovered early and countered with an antidote

Answer 15

example of mitigation; near miss error

Question 16

Sentinel event

Answer 16

an unexpected occurrence involving death or serious physical or psychologic injury

Question 17

serious injusry

Answer 17

includes loss of limb or function

Question 18

sentinel events

Answer 18

signal the need for immediate investigation and response

Question 19

How many types of errors

Answer 19

four

Question 20

Diagnostic errors

Answer 20

result of a delay in diagnosis, failure to employ indicated tests, use of outmoded tests, or failure to act on results of monitoring or testing.

Question 21

treatment errors

Answer 21

occur in the performance of an operation, procedure, or test; in the administration of a treatment; in the dose or method of administering a drug; or in avoidable delay in treatment or in responding to an abnormal test result.

Question 22

Preventive errors

Answer 22

occur when there are failures to provide any of the following: prophylactic treatment, adequate monitoring, or follow-up treatment.

Question 23

Communication errors

Answer 23

occur from failure of communication

Question 24

placement of errors described as

Answer 24

active or latent (etiology of the error)

Question 25

active errors

Answer 25

“sharp end”

Question 26

latent conditions

Answer 26

contributing factors that are hidden and lie inactive in the health care delivery system

Question 27

latent failure

Answer 27

is a flaw in a system that does not immediately lead to an accident, but establishes a situation in which a triggering event may lead to an error

Question 28

latent error

Answer 28

more organizational, contextual, and diffuse in nature, or design-related—are called errors occurring at the “blunt end.”

Question 29

example, a nurse who administers the incorrect medication because of a failure to check the medication order

Answer 29

active error

Question 30

example, a latent error can lead to an active error

Answer 30

Pyxis is incorrectly stocked

Question 31

7 aspects of safety culture

Answer 31

leadership, teamwork, an evidence base, communication, learning, a just culture, and patient-centered care

Question 32

RCA

Answer 32

root cause analysis

Question 33

FMEA

Answer 33

failure mode effects analysis

Question 34

Communication failures

Answer 34

are the leading cause of inadvertent patient harm

Question 35

Human factors

Answer 35

interrelationships between people, technology, and the environment in which they work

Question 36

hazard

Answer 36

anything that increases the probability of errors or patient/employee injury

Question 37

Effective care coordination

Answer 37

checklists and other strategies to ensure safe hand-offs between providers or settings

Question 38

Crew resource management training

Answer 38

standardize procedures, standardize communication, decrease errors, and increase efficiency

Question 39

work environments of health care

Answer 39

characteristics of high stress, complexity, the need for highly functioning teams, the importance of accurate and precise communication, and the high cost of system failures

Question 40

six critical components of crew resource management

Answer 40

(1) situational awareness (2) problem identification (3) decision making through generation of alternative acceptable solutions (4) appropriate workload distribution (5) time management (6) conflict resolution

Question 41

HRO

Answer 41

High-reliability organizations

Question 42

HROs

Answer 42

manage work that involves hazardous environments