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Therapeutics 4 Kappa Epsilon > Safety Quiz 3 > Flashcards

Safety Quiz 3 Flashcards

1
Q

Definitions:

Lean?

A

process of improvement approach focused on RESPECTING INDIVIDUALS and REMOVING WASTE from a system

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2
Q

Definitions:

Six Sigma?

A

process improvement method used to REMOVE VARIATION from a system

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3
Q

Definitions:

PDSA?

A

Plan-Do-Study-Act

process improvement method that tests small changes to improve a system

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4
Q

______ started in 1941 and created by W.Edward Deming

A

PDSA Cycle

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5
Q

_____ started around 1940s-1990s by Toyota company

A

Lean

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6
Q

_____ started in 1986 by Motorola

A

six sigma

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7
Q

FMEA stands for?

A

Failure Modes and Effects Analysis

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8
Q

what is FMEA?

A

a prospective analysis of the safety of a system, process, technology, or device.

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9
Q

what is RCA^2

A

is a retrospective analysis of an actual safety event

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10
Q

what does RCA^2 stand for

A

Root Cause Analysis and Action

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11
Q

T or F: both RCA^2 and FMEA originate from human factors discipline

A

true

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12
Q

Root Cause Analysis:

identify ________ and _______

A

the factors that underlie variation in performance AND potential improvements

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13
Q

Root Cause Analysis:

focuses primarily on ______ and _______

A

primarily on systems and processes

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14
Q

Root Cause Analysis:

decrease _______ of such events

A

the likelihood

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15
Q

Goal of RCA2:

learn from ______ and ______

A

from adverse events and

take action

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16
Q

questions to ask with RCA2:

A 
What happened?
What system (factors contributed?)
What actions (can we do)
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17
Q 
Timeline of RCA:
\_\_\_\_ an a safety event
\_\_\_\_\_\_ any associated pts risk first
decide need for RCA2 within \_\_\_\_\_\_
Complete RCA2 within \_\_\_\_\_\_
A

AFTER an event
mitigate any assoc risk
within 72 hours
complete 30 - 45 days

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18
Q

All _______ events must be reviewed by the hospital and are subject to review by the Joint comission

A

sentinel events

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19
Q

Required Hospital Response to a Sentinel event:

A

Formalized team response (pt and family)
Notify hospital leadership
Investigation
Analysis
Develop strong corrective to result in sustainable improvement
Timeline for implementation of corrective actions
Demonstrate systemic improvement (monitoring)

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20
Q

Indiana Requirements of a Sentinel Event?

A

Mandatory reporting to the Dept of Health

– Must report findings within 15 days of discovery

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21
Q

Steps of RCA2 ?

A
  1. Assemble the RCA2 team
  2. Gather facts
  3. Identify root causes
  4. Design and implement risk reduction strategies
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22
Q

RCA2 Team:
__#__ people
people should have basic understanding of human factors
______ team

A

4 - 6

interdisciplinary team

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23
Q

RCA Team: Interdisciplinary —
who should be in this?
and who should not?

A

-Clinical subject matter expert
-Individual naïve to the clinical area
-Front line staff who works with similar clinical processes
-Patient representative
-leader versed in RCA2
(NO ONE from the actual event should be apart of this)

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24
Q

3 parts of Burnout?

A

emotional exhaustion
depersonalization/cynicism
decreased sense of personal accomplishment

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25
Q

Burnout syndrome definition?

A

A prolonged response to chronic emotional and interpersonal stressors on the job

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26
Q

what survey can be given to check if someone is burnout?

A

MBI – Maslach Burnout Inventory

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27
Q

what is periodization?

A

From athletic training, involves intense periods of stress followed by specific rest to allow for growth

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28
Q

growth equation =?

A

stress + rest

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29
Q

what are examples of HROs

A
  • Aircraft carrier operations
  • Electrical power grid operations
  • Wildland firefighting
  • Nuclear Power Generation
  • Commercial Aviation and Air Traffic Control
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30
Q

5 characteristics of an HRO

A

preoccupation with failure
reluctance to simplify
sensitivity to operations

deference to expertise
commitment to resilience

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31
Q

Process Flow Maps:
Blue spots = _____
Diamond shapes = ______
Squares = ______

A

blue spots = start and stop of the process
Diamond = yes or no places
Squares = each step

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32
Q

SMART goals stand for?

A 
specific 
measurable
actionable
realistic
time bound
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33
Q

what does “muda” mean?

A

waste!

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34
Q

what are possible issues/muda(waste) in a process? (from Anderson lecture)

A 
defects
transportation
motion
inventory
waiting
overproduction
overprocessing
human potential
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35
Q

when developing solutions – each solution is seen as high or low ______
or
high or low _____

A

impact

or effort

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36
Q

when developing solutions – when high or low impact or effort:
want to avoid “_____”
and strive for “____”

other two boxes are “_____” and “____”

A

avoid “thankless tasks” - high effort and low impact
strive for “quick wins” low effort and high impact

others: “fill ins” – low and low
“major projects” – high and high

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37
Q

what is the 5S tool?

A 
sort
straighten
shine
standardize
sustain
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38
Q

what does PDSA stand for

A

plan (find problems)
do (test solutions)
study (results)
act (implement best solution)

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39
Q

Six Sigma:

reduces _____ and improves _____

A

reduce variability

improves reliability

40
Q

idea behind six sigma?

A

anything out of 6 “sigmas” aka
anything out of 3 standard deviations on each side = unpredictable parts – we want everything to happen within those 6 sigmas

41
Q

RCA2 or FMEA?

which one is retrospective and which one is prospective?

A 
RCA = retrospective
FMEA = prospective
42
Q

when looking at causation – the “5 rules of causation”

focus on _______

A

system issues

43
Q

when looking at causation – the “5 rules of causation”
Promote description of:
____ –> _____ –> _____

A

cause
effect
event

44
Q 
the "5 rules of causation" Summary:
Rule #1: \_\_\_\_\_\_\_\_\_\_\_
Rule #2: \_\_\_\_\_\_\_\_\_\_\_
Rule #3: \_\_\_\_\_\_\_\_\_\_\_
Rule #4: \_\_\_\_\_\_\_\_\_\_\_
Rule #5: \_\_\_\_\_\_\_\_\_\_\_
A

1: clearly show “cause and effect” relationship
2: use specifics - NO negative or vague words
3: human errors must have a preceding cause
4: violations must have a preceding cause
5: “failure to act” is only casual when there is a pre-existing duty to act

45
Q

what is hazard control hierarchy?

A

risk reduction strategies.. hierarchy because some are “stronger” than others

there are 5 different levels

46
Q

what are the 5 different levels of hazard control hierarchy?

lowest safety strength to highest safety strength

A

(lowest)

accept risk –> legislation –> warn/train –> safeguard –> elimination (highest)

47
Q

hazard control hierarchy:

what does it mean to “accept risk”?

A

do nothing…

48
Q

hazard control hierarchy:

what does it mean to do “legislation”?

A

develop policies/procedures that describe how to avoid the risks

49
Q

hazard control hierarchy:

what does it mean to “warn or train?”

A

educate individuals about the risk

50
Q

hazard control hierarchy:

what does it mean to “safeguard”?

A

add a barrier or change the pathway to harm to reduce risk

51
Q

hazard control hierarchy:

what does it mean to “eliminate”?

A

design out the source of the hazard to remove the risk

52
Q 
RCA2 summary:
Act (fast or slow)
Focus on \_\_\_\_\_ changes
Identify causes via "\_\_\_ rules"
Not used to \_\_\_\_\_\_\_
Implement and monitor actions to intervene
A

act fast
focus on system changes
via 5 rules
NOT used to pinpoint blame

53
Q

how to find RPN in FMEA process

A

likelihood of occurrence x likelihood of detection x severity

54
Q

3 possible roles of patient safety organizations

A

regulatory
accreditation/quality
professional

55
Q

Healthcare Worker Safety:
Agencies?
_______ Drug List

A

CDC and CIOs (CDC Centers, institute, offices)

NIOSH Hazardous Drug List

56
Q

NIOSH Hazardous Drug List
Group 1 of drugs: __________
Group 2 of drugs: __________
Group 3 of drugs: __________

A

1: antineoplastics
2: non-antineoplastics that meet some NIOSH criteria
3: pose a REPRODUCTIVE risk to men and women

57
Q

PSO is different from a patient safety organization….:

PSO is a specific designation provided by the _________

A

Agency for Healthcare Research and Quality (AHRQ)

58
Q

PSO is different from a patient safety organization….:

PSOs must follow rules enacted by ____

A

HHS

59
Q

where errors should be reported?

If it is a mandatory reporting — what are the two organizations

A

state program

joint comission

60
Q

ISMP Reading 10/4/18:

what has been a common mix up seen in labor and delivery units

A

epidural analgesia and IV abx

61
Q

ISMP Reading 10/4/18:

what things led to the confusion b/w fentanyl and penicillin bags in the labor/delivery situation

A

drug shortage on 100 mL bags – so both in 50 mL (which is different)
(thus the typical bright yellow label on the bag was not on the bag either)

62
Q

what is the reversing antidote for when epidural analgesia is given by accident

A

naloxone

and lipid emulsion

63
Q

safe practice recommendations for fixing the mix ups seen in labor/delivery —
prescribing changes?

A

have physician/anesthesia and pharmacist check before infusion

use less cardiotoxic meds (aka do NOT use bupivacaine)

64
Q

safe practice recommendations for fixing the mix ups seen in labor/delivery —
dispensing changes?

A 
scan bags
let ppl know drug shortages aka if bags look different
use auxillary labels 
differentiate bags
dispense with epidural tubing
65
Q 
Characteristics of a team:
A team = 2 or more individuals that....
interact \_\_\_\_\_\_
have a common \_\_\_\_\_\_
and coordinate as a result of  \_\_\_\_\_\_\_\_\_
A

interact dynamically

common goal

task interdependency

66
Q

Characteristics of a team:
A team = 2 or more individuals that….
Have ______ roles
Posses ________ and ______ skills

A

specific roles

specialized and complementary skills

67
Q

3 Main Safety Communication Approaches for Teams?

A

Closed Loop Communication/talk back/check back
two challenge rule
D.E.S.C for conflict resolution

68
Q

what is closed loop communcation

A

person 1 says something
person 2 repeats it to confirm it
person 1 is like yah, das right

69
Q

what is the 2 challenge approach

A

1st challenge: usually pose a question

2nd challenge: restate concerns

70
Q

what does DESC stand for

A

Describe, Express, Suggest, Consequences

71
Q

what is the DESC process

A

describe situation
express concern
suggest alternatives
state consequences

72
Q

What are some challenges to effective teamwork?

A 
Disperse settings  
Hierarchies
Individualistic nature of healthcare 
Instability of teams
Technology*
73
Q

8 components of Teams…

A 
Leadership
Mutual performance monitoring
Back-up behavior
Adaptability
Team orientation
Shared Mental Models
Closed-Loop Communication
Mutual Trust
74
Q

ISMP Article 10/18:

what was the issue with glucometers?

A

the accu-check inform II would have a weird reading error with low glucose — nurses misinterpreted and gave insulin instead of juice/dextrose :(

meter would say RR LO or CR LO/out of critical range

75
Q

ISMP Article 10/18:

what organization did a study on the glucometers and what did they see that “fixed” the problems

A

VA did the study

if the numbers were on the screen - nurses did not have any issues

76
Q

ISMP Article 10/18:

what were some modifications to the meters one could to fix the meter problem

A

make the readable range much larger to avoid the RR LO rejections…
have meter present numeric values…
during education programs - make trainees aware of the alarms

77
Q

ISMP Article 10/18:

recent Vitamin A/D label change?

A

it reports strength in mcg and NOT IU

78
Q

ISMP Article 10/18:

Rocuronium vial label issue?

A

nurse say that vial said 10mg/mL – but vial was 5 mL and if you peeled off the top label you saw it was 50 mg/5mL…

79
Q

ISMP Article 10/18:

Common drug abbreviations they mentioned that are a problem… why are they an issue

A

tPA, TKA, TPN, TXA
1st two = fibrinolytic agents (used in stroke pts)
TXA = for STOPPING a hemorrhage

80
Q

ISMP Article 11/01:

common mispractices with IV push medications

A

administration of prefilled syringes/catridges as vials..

diluting the vials even though they are already to go

81
Q

ISMP Article 11/01:

drugs most commonly NOT provided in ready to administer syringes?

A 
antiemetics
antipsychotics
benzos
abx
opioids
pantoprazole
metoprolol
furosemide
82
Q

Online Module:

what is the theory about CDS?

A

Bayesian probability theory

83
Q

Online Module:

“First” CDS?

A

Leeds Abdominal Pain System

84
Q

What are some CDSS that were helpful in the evolution of todays current CDSS
(old ones were RULES-based)

A

MYCIN
or
HELP

85
Q

Online Module:

Boone said CDS has 3 different inputs.. what are those inputs?

A

Algorithms/knowledge about how make inferences

Instance Data describing specific case

Ontological or “world knowledge”, representing facts about the world (ex: how genes and disesase work)

86
Q

Online Module:

CDSS Requirements?

A
  • Knowledge base
  • Program for combining the knowledge with patient-specific information
  • Communication mechanism
87
Q

Online Module:

5 rights for CDSS?

A 
Right information
To the right person
In the right format
Through the right channel
At the right time
88
Q

what projects are underway to hopefully improve CDS

A

IOM studies
ONC initiatives
Meaningful use objectives/measures

89
Q

ISMP Article 11/01:

what was the sound alike look alike issue?

A

Migalastat and Miglustat

90
Q

ISMP Article 11/01:

Migalastat and Miglustat – what are some reasons that this mix up is quite likely/aka what are their similarities

A

both are to supplement an enzyme deficiency related to a fat disorder….
both only come in one strength (aka very easy for the prescriber to not annotate which strength)

91
Q

ISMP Article 11/01:

Perioperative area needs barcode scanning — what happened that led this to being in the article

A

anesthesiologist gave IV lidocaine and not IV fentanyl because both were standing upright in a bin and both have light blue vial tops
(thus scanning would prevent the mix up – also ADCs could help to keep labels straightened and kept forward)

92
Q

ISMP Article 11/01:

Issue with WinRho SDF?

A

label has IU and mcg on label —- makes dose drawing and prescribing confusing and wack

93
Q

ISMP Article 11/01:

People are diluting IV push medications – which container type are people LESS likely to do this

A

pharmacy syringe w/ pt specific dose

94
Q

ISMP Article 11/01:

People are diluting IV push medications – which container type are people MORE likely to do this

A

single dose vials

95
Q

ISMP Article 11/01:

what drugs are most likely to be diluted for IV push

A

opioids
anxiolytics/antipsychotics
antiemetics

96
Q

who is Koppel? why does he matter?

A

he is a sociologist who studies hospital work (about medical error reporting)

97
Q

Medication Error Reporting - Online Module:

_____ is source of errors

A

CPOE

Therapeutics 4 Kappa Epsilon (16 decks)

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