Part One Flashcards
Two streams?
Professional competence
Human performance
Most important spur to pt safety?
1999 institute of medicine report.
Improvement process?
FOCUS
Find a process to improve Organize Clarify what is known Understand variation Select a process improvement
Cycle to initiate process improvement?
Plan-do-study-act Cycle
3 models of culture?
Artifacts
Espoused values
Basic assumptions
Basic assumptions
Implicit
Taken for granted
Unconscious
Espoused values
Mission statement
Artifacts
Visible expressions of ED culture.
Posters
Dress code
Professional language
HRO
High reliability organization
High risk, few failures
Safe culture factors
Commitment
Competence
Cognizance
Barriers to improving culture
No limits in production Excessive autonomy Craftsman’s attitude Ego centered safety protection Loss of visibility of risk.
No limits in production
No limits, overcrowding, surge
Excessive autonomy
Teamwork vs cowboy approach
Practical legal and cultural barriers
Craftsman attitude
Standardization is the opposite—not always well received.
Ego centered safety protection
Addressing errors at system—not the fearful individual level.
