Human Error Prevention Tools
These are a vital barrier for preventing events.
What are Human Error Prevention Tools?
An error that does not reach the patient.
What is a "near-miss"?
Everyone makes a personal commitment to safety
Everyone is accountable for clear and complete communication
Everyone supports a questioning attitude
What are the expected safety behaviors for all GCH staff?
Asking a team member to review your plan.
What is team member checking?
This is often used when there is a need to ensure communication is clear.
What is 3-Part Communication
Operates under high risk conditions all the time, yet manages to have very few accidents.
What is a high reliability organization?
A task that is routine and familiar - we don't even have to think about the task while we are doing it.
What is skill based performance?
The combination of probability and consequence.
What is risk?
Expressing a Concern
Stating you're Uncomfortable
This is a Safety issue
CUSs
What is an example of a safety escalation technique?
Used when verbally communicating all alpha or alpha numeric designations
What is Phonetic Alphabet?
Keep me safe, heal me, be nice to me.
What does high reliability mean to a patient and family?
The percentage of errors that occur because we have chosen to use the wrong rule, misapply a rule, or we have been non-compliant with a rule.
What is the reason 77% of hospital errors occur?
High risk situation + high risk behavior =
What is a safety event?
Stop
Think
Act
Review
STAR
What is a "mental time-out" that helps someone pay attention to detail?
When communicating, the sender initiates, the receiver acknowledges, and the sender confirms by saying "that's correct".
What is three-part communication?
The number of events that cause moderate to severe harm or death per 10,000 patient days.
What is the serious safety event rate (SSER)?
Choosing not to check a patient's armband before administering a medication.
What is a rule based error (non-compliance)?
Reducing human error and finding/fixing systems results in this.
What is a reduction in safety events.
This is when you are distracted, multi-tasking, under time pressure, before a safety critical action.
What is an example of a STAR moment?
The number of clarifying questions necessary to decrease miscommunication due to wrong assumptions.
What is two?
* 3 questions are perceived as annoying!
Three per 10,000 patient days.
What is the current GCH serious safety event rate (SSER)?
* we want to be below 1!
The way we eliminate preventable patient and staff safety events.
What is safety as a core value?
The third leading cause of death in the U.S.
What is medical error?
The amount of effort we need to put into our personal and team commitment to safety.
What is 200%?
An effective tool for having a questioning attitude.
What is QVV? Qualify, Validate, & Verify.
*qualify - do I trust this source?
*validate - does this make sense?
*verify - check it with an expert.