Reporting Flashcards
Number one contributing factor for sentinel events
Communication failure
Signal of safety culture that is a proactive opportunity to improve before significant event occurs
Near miss reporting
What was designed to improve patient safety through analysis of reporter events and reduction or elimination of the risks and hazards associated with the delivery of patient care
The patient safety and quality improvement act of 2005
What are the roles of learning boards?
- Provide space to share defects
- Promote visibility of threats and missteps
- Show resolution of defects
- Promote threat awareness and reporting behaviors to enhance a culture of safety
Proactive vs reactive risk assessment
Proactive - failure modes and effects analysis (fmea)
Reactive - root cause analysis (rca)
What are the two characteristics of a good rca?
Thorough and Credible
Describe pitfalls of bundles vs check lists
Bundles- not check lists and are all or nothing
Checklist- done out of order, no buy in, lack of ownership
What percentage of medication errors have an HIT component
25%
What are the components of a risk priority number (rpn)
Severity 1-5 5 is bad (worst possible outcome)
Detect ability 1-5 5 is bad(detection not possible before reaching patient)
Frequency 1-5 increasing frequency
Controls 1 3 5 (does the control work? 5 =no)
What represents science at the intersection of psychology and engineering looking at all aspects of a work system to support human performance and safety.
Human Factors Analysis
What are the components of systems that determine safety?
People Tasks Tools/technology Environment Organization
What are the 3 steps in the design strategy?
- Standardize and simplify
- Application of controls
- Catch errors and mitigate harm
What are the five principles of high reliability organizations with examples
- Sensitivity to operations - heightened awareness of the state of relevant systems and processes
- Reluctance to simplify- the work is complex and there is potential to fail
- Preoccupation with failure - view near misses as opportunities to improve rather than proof of success
- Deference to expertise- value expertise over seniority
- Practicing resilience- prioritize emergency training for many unlikely but possible failures
What are the components of crew resource management?
Leadership Co-operation Situation awareness Decision making Communication
Link the diagrams/charts to what they illustrate:
Fishbone diagram
Control chart
Spaghetti chart
Pareto diagram
Fishbone = root cause analysis/ cause and effect
Control chart = similar to run chart. Shows trends over time in relation to quality improvement
Spaghetti chart = part or lean to show workflows and redundancies
Pareto = shows frequency of defects and their cumulative impact.
What best demonstrates non random process variation over time?
Control chart—- step up from run chart as it had upper and lower control limits to measure usual and unusual variation.
What bias accepts a diagnosis before it has been fully verified accounting for high proportion of missed diagnosis
Premature closure
What is anchoring bias?
Over reliant on the first piece of information they hear.
What is the availability heuristic?
Overestimate the importance of information that is available to them.
Name the four tests to determine culpability
- Deliberate?
- Incapacity?
- Foresight? Related to short cuts
- Substitution test? Could someone else placed in same position have made same error. If so error is blameless
Describe the following errors:
Active vs latent
Omission vs comission
Active- errors and violations having immediate neg results. Caused by indiv
Latent- caused by circumstances of the system. Caused by org
Omission - not doing something you should have done
Commission- doing something you should not have done
What does a balance measure do?
Fixes one issue and causes another
