Safety Quiz 3 Flashcards
Definitions:
Lean?
process of improvement approach focused on RESPECTING INDIVIDUALS and REMOVING WASTE from a system
Definitions:
Six Sigma?
process improvement method used to REMOVE VARIATION from a system
Definitions:
PDSA?
Plan-Do-Study-Act
process improvement method that tests small changes to improve a system
______ started in 1941 and created by W.Edward Deming
PDSA Cycle
_____ started around 1940s-1990s by Toyota company
Lean
_____ started in 1986 by Motorola
six sigma
FMEA stands for?
Failure Modes and Effects Analysis
what is FMEA?
a prospective analysis of the safety of a system, process, technology, or device.
what is RCA^2
is a retrospective analysis of an actual safety event
what does RCA^2 stand for
Root Cause Analysis and Action
T or F: both RCA^2 and FMEA originate from human factors discipline
true
Root Cause Analysis:
identify ________ and _______
the factors that underlie variation in performance AND potential improvements
Root Cause Analysis:
focuses primarily on ______ and _______
primarily on systems and processes
Root Cause Analysis:
decrease _______ of such events
the likelihood
Goal of RCA2:
learn from ______ and ______
from adverse events and
take action
questions to ask with RCA2:
What happened? What system (factors contributed?) What actions (can we do)
Timeline of RCA: \_\_\_\_ an a safety event \_\_\_\_\_\_ any associated pts risk first decide need for RCA2 within \_\_\_\_\_\_ Complete RCA2 within \_\_\_\_\_\_
AFTER an event
mitigate any assoc risk
within 72 hours
complete 30 - 45 days
All _______ events must be reviewed by the hospital and are subject to review by the Joint comission
sentinel events
Required Hospital Response to a Sentinel event:
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)
Indiana Requirements of a Sentinel Event?
Mandatory reporting to the Dept of Health
– Must report findings within 15 days of discovery
Steps of RCA2 ?
- Assemble the RCA2 team
- Gather facts
- Identify root causes
- Design and implement risk reduction strategies
RCA2 Team:
__#__ people
people should have basic understanding of human factors
______ team
4 - 6
interdisciplinary team
RCA Team: Interdisciplinary —
who should be in this?
and who should not?
-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)
3 parts of Burnout?
emotional exhaustion
depersonalization/cynicism
decreased sense of personal accomplishment
Burnout syndrome definition?
A prolonged response to chronic emotional and interpersonal stressors on the job
what survey can be given to check if someone is burnout?
MBI – Maslach Burnout Inventory
what is periodization?
From athletic training, involves intense periods of stress followed by specific rest to allow for growth
growth equation =?
stress + rest
what are examples of HROs
- Aircraft carrier operations
- Electrical power grid operations
- Wildland firefighting
- Nuclear Power Generation
- Commercial Aviation and Air Traffic Control
5 characteristics of an HRO
preoccupation with failure
reluctance to simplify
sensitivity to operations
deference to expertise
commitment to resilience
Process Flow Maps:
Blue spots = _____
Diamond shapes = ______
Squares = ______
blue spots = start and stop of the process
Diamond = yes or no places
Squares = each step
SMART goals stand for?
specific measurable actionable realistic time bound
what does “muda” mean?
waste!
what are possible issues/muda(waste) in a process? (from Anderson lecture)
defects transportation motion inventory waiting overproduction overprocessing human potential
when developing solutions – each solution is seen as high or low ______
or
high or low _____
impact
or effort
when developing solutions – when high or low impact or effort:
want to avoid “_____”
and strive for “____”
other two boxes are “_____” and “____”
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
what is the 5S tool?
sort straighten shine standardize sustain
what does PDSA stand for
plan (find problems)
do (test solutions)
study (results)
act (implement best solution)
Six Sigma:
reduces _____ and improves _____
reduce variability
improves reliability
idea behind six sigma?
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
RCA2 or FMEA?
which one is retrospective and which one is prospective?
RCA = retrospective FMEA = prospective
when looking at causation – the “5 rules of causation”
focus on _______
system issues
when looking at causation – the “5 rules of causation”
Promote description of:
____ –> _____ –> _____
cause
effect
event
the "5 rules of causation" Summary: Rule #1: \_\_\_\_\_\_\_\_\_\_\_ Rule #2: \_\_\_\_\_\_\_\_\_\_\_ Rule #3: \_\_\_\_\_\_\_\_\_\_\_ Rule #4: \_\_\_\_\_\_\_\_\_\_\_ Rule #5: \_\_\_\_\_\_\_\_\_\_\_
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
what is hazard control hierarchy?
risk reduction strategies.. hierarchy because some are “stronger” than others
there are 5 different levels
what are the 5 different levels of hazard control hierarchy?
lowest safety strength to highest safety strength
(lowest)
accept risk –> legislation –> warn/train –> safeguard –> elimination (highest)
hazard control hierarchy:
what does it mean to “accept risk”?
do nothing…
hazard control hierarchy:
what does it mean to do “legislation”?
develop policies/procedures that describe how to avoid the risks
hazard control hierarchy:
what does it mean to “warn or train?”
educate individuals about the risk
hazard control hierarchy:
what does it mean to “safeguard”?
add a barrier or change the pathway to harm to reduce risk
hazard control hierarchy:
what does it mean to “eliminate”?
design out the source of the hazard to remove the risk
RCA2 summary: Act (fast or slow) Focus on \_\_\_\_\_ changes Identify causes via "\_\_\_ rules" Not used to \_\_\_\_\_\_\_ Implement and monitor actions to intervene
act fast
focus on system changes
via 5 rules
NOT used to pinpoint blame
how to find RPN in FMEA process
likelihood of occurrence x likelihood of detection x severity
3 possible roles of patient safety organizations
regulatory
accreditation/quality
professional
Healthcare Worker Safety:
Agencies?
_______ Drug List
CDC and CIOs (CDC Centers, institute, offices)
NIOSH Hazardous Drug List
NIOSH Hazardous Drug List
Group 1 of drugs: __________
Group 2 of drugs: __________
Group 3 of drugs: __________
1: antineoplastics
2: non-antineoplastics that meet some NIOSH criteria
3: pose a REPRODUCTIVE risk to men and women
PSO is different from a patient safety organization….:
PSO is a specific designation provided by the _________
Agency for Healthcare Research and Quality (AHRQ)
PSO is different from a patient safety organization….:
PSOs must follow rules enacted by ____
HHS
where errors should be reported?
If it is a mandatory reporting — what are the two organizations
state program
joint comission
ISMP Reading 10/4/18:
what has been a common mix up seen in labor and delivery units
epidural analgesia and IV abx
ISMP Reading 10/4/18:
what things led to the confusion b/w fentanyl and penicillin bags in the labor/delivery situation
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)
what is the reversing antidote for when epidural analgesia is given by accident
naloxone
and lipid emulsion
safe practice recommendations for fixing the mix ups seen in labor/delivery —
prescribing changes?
have physician/anesthesia and pharmacist check before infusion
use less cardiotoxic meds (aka do NOT use bupivacaine)
safe practice recommendations for fixing the mix ups seen in labor/delivery —
dispensing changes?
scan bags let ppl know drug shortages aka if bags look different use auxillary labels differentiate bags dispense with epidural tubing
Characteristics of a team: A team = 2 or more individuals that.... interact \_\_\_\_\_\_ have a common \_\_\_\_\_\_ and coordinate as a result of \_\_\_\_\_\_\_\_\_
interact dynamically
common goal
task interdependency
Characteristics of a team:
A team = 2 or more individuals that….
Have ______ roles
Posses ________ and ______ skills
specific roles
specialized and complementary skills
3 Main Safety Communication Approaches for Teams?
Closed Loop Communication/talk back/check back
two challenge rule
D.E.S.C for conflict resolution
what is closed loop communcation
person 1 says something
person 2 repeats it to confirm it
person 1 is like yah, das right
what is the 2 challenge approach
1st challenge: usually pose a question
2nd challenge: restate concerns
what does DESC stand for
Describe, Express, Suggest, Consequences
what is the DESC process
describe situation
express concern
suggest alternatives
state consequences
What are some challenges to effective teamwork?
Disperse settings Hierarchies Individualistic nature of healthcare Instability of teams Technology*
8 components of Teams…
Leadership Mutual performance monitoring Back-up behavior Adaptability Team orientation Shared Mental Models Closed-Loop Communication Mutual Trust
ISMP Article 10/18:
what was the issue with glucometers?
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
ISMP Article 10/18:
what organization did a study on the glucometers and what did they see that “fixed” the problems
VA did the study
if the numbers were on the screen - nurses did not have any issues
ISMP Article 10/18:
what were some modifications to the meters one could to fix the meter problem
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
ISMP Article 10/18:
recent Vitamin A/D label change?
it reports strength in mcg and NOT IU
ISMP Article 10/18:
Rocuronium vial label issue?
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…
ISMP Article 10/18:
Common drug abbreviations they mentioned that are a problem… why are they an issue
tPA, TKA, TPN, TXA
1st two = fibrinolytic agents (used in stroke pts)
TXA = for STOPPING a hemorrhage
ISMP Article 11/01:
common mispractices with IV push medications
administration of prefilled syringes/catridges as vials..
diluting the vials even though they are already to go
ISMP Article 11/01:
drugs most commonly NOT provided in ready to administer syringes?
antiemetics antipsychotics benzos abx opioids pantoprazole metoprolol furosemide
Online Module:
what is the theory about CDS?
Bayesian probability theory
Online Module:
“First” CDS?
Leeds Abdominal Pain System
What are some CDSS that were helpful in the evolution of todays current CDSS
(old ones were RULES-based)
MYCIN
or
HELP
Online Module:
Boone said CDS has 3 different inputs.. what are those inputs?
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)
Online Module:
CDSS Requirements?
- Knowledge base
- Program for combining the knowledge with patient-specific information
- Communication mechanism
Online Module:
5 rights for CDSS?
Right information To the right person In the right format Through the right channel At the right time
what projects are underway to hopefully improve CDS
IOM studies
ONC initiatives
Meaningful use objectives/measures
ISMP Article 11/01:
what was the sound alike look alike issue?
Migalastat and Miglustat
ISMP Article 11/01:
Migalastat and Miglustat – what are some reasons that this mix up is quite likely/aka what are their similarities
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)
ISMP Article 11/01:
Perioperative area needs barcode scanning — what happened that led this to being in the article
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)
ISMP Article 11/01:
Issue with WinRho SDF?
label has IU and mcg on label —- makes dose drawing and prescribing confusing and wack
ISMP Article 11/01:
People are diluting IV push medications – which container type are people LESS likely to do this
pharmacy syringe w/ pt specific dose
ISMP Article 11/01:
People are diluting IV push medications – which container type are people MORE likely to do this
single dose vials
ISMP Article 11/01:
what drugs are most likely to be diluted for IV push
opioids
anxiolytics/antipsychotics
antiemetics
who is Koppel? why does he matter?
he is a sociologist who studies hospital work (about medical error reporting)
Medication Error Reporting - Online Module:
_____ is source of errors
CPOE
