Need To Know Flashcards
Unsafe acts committed by people who are in direct contact with a patient or system
Active failures
These take a variety of forms slips labs fumbles mistakes and procedural violations
Active failures
What are inevitable resident pathogens within the system
Latent conditions
Do you sunrise from decisions made by designers builders procedure writers top level management
Latent conditions
Latent conditions have two kinds of adverse effect, first one is
They can translate into erro provoking conditions within the local workplace (for example: time pressure, understaffing, inadequate equipment, fatigue and inexperience)
What is the second kind of adverse effect that latent conditions have
They can create long lasting holes or weaknesses in the defenses (examples untrustworthy alarms and indicators, unworkable procedures, design and construction deficiencies
Can latent conditions lie dormant within the system for many years before they combine with active failures and local triggers to create an accident opportunity?
Yes
Which kind of failure can be identified and remedy before an adverse event occurs
Latent condition
What is the most distinguishing feature of a highly reliability organization
Collective preoccupation with the possibility of failure they expect to make errors and trainer workforce to recognize and recover from them
Physical changes to the work environment, forcing functions, simplification of the process, and standardization -these actions can be placed in which category
Stronger actions from an RCA
Double checks, new procedures, trainings and warnings are in which category of actions
Weakest in RCA
Redundancy, enhanced documentation or communication, eliminating look alike and sound likes, read back, checklist cognitive aids, reduce distractions, software modifications, increase staffing or which category of actions
Intermediate
