Red Rules
Safety Strategies
More Safety Strategies
Communication
Reliable Behaviors
100
Two patient identifiers (name, DOB, MR number)
What is the only acceptable method of verifying patient identity.
100
S-T-A-R (Stop, Think, Act, Review)
What is a method of self-checking to be sure the action to be taken is the desired action? This safety strategy is best used to avoid errors related to routine tasks, when there is chaos, distractions or interruptions, when one is fatigued or preoccupied or when a mistake could lead to a serious consequence.
100
A communication process for care providers to discuss pertinent patient information due to a change in care providers, a change in patient condition or prior to the patient leaving the assigned unit for tests or treatments in other areas of the hospital.
What is handoff communication?
100
Used as a communication technique when there is a high risk situation or when information is incomplete and/or ambiguous.
What is a clarifying question?
100
Sender initiates communication -> Receiver repeats back -> Send acknowledges accuracy by saying "That's correct" or :That's not correct."
What is a 3-way communication, 3-way repeat back or Three-peat?
200
Time Out Process
What is a standardized procedure conducted immediately before a surgery or invasive procedure that involves the entire team as they verify the right patient, right procedure and right site.
200
A "no blame" culture must be balanced with this...
What is accountability?
200
A term used to describe the expression of concern for safety or the use of the chain of command to assure patient safety.
What is Speak Up?
200
In healthcare, this has been correlated to adverse events and higher patient morbidity and mortality.
What is poor teamwork and communication?
200
"50 milligrams, that is five zero, fifty milligrams."
What is numeric clarification?
300
Two provider check
What is the process used before the administration of blood products or high risk medications that provides confirmation that the correct action is about to be taken.
300
The patient was suppose to have a renal biopsy but the hospital did a liver biopsy by mistake. What are the possible safety strategies that were missed to prevent this error?
What is a time out? What is a validation of the consent against the procedural order? What is marking the site? What is S-T-A-R? What is involving the patient? What is escalation, ARCC or speak up?
300
A team member who is trained to observe employee work behaviors and provide feedback about practice and compliance with Memorial Hermann practice and compliance with our behavior expectations that prevent events of harm and Make Every Day A Safe Day.
What is a safety coach?
300
A communication style that destroys trust and leads to the desire to not speak up due to fear.
What is disrespectful communication?
300
"I am parked in area D-2, that is D as in dog."
What is phonetic clarifications?
400
Red Rules help avoid this--which is defined as "any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness."
What is a Sentinel Event?
400
A strategy used to escalate a situation in which one feels uncomfortable or concern for safety. Ask a question, Request a change, State your concern for safety, Enact the Chain of Command.
What is ARCC?
400
Independent double checking
What is a process involving two individuals, in which the responsibility of the second individual is to verify the work performed by the first.
400
Just as copilots have been reluctant to speak up to pilots, health care workers are sometimes reluctant to speak up to physicians or those seen as having more authority or expertise. This phenomenon is known as...
What is authority gradient?
400
A communication tool used to focus the sender of the communication and is quick and to the point. "Here's the situation....Let me give you a little background...My assessment is...My recommendation is or, what is your recommendation?"
What is SBAR (Situation, Background, Assessment, Request).
500
95%
What is the percentage of error that can be eliminated if a effective double check process is in place?
500
If this action is not taken it is difficult to learn from errors or recognize trends and opportunities for improvement.
What is reporting of errors?
500
You are leaving a code blue and overhear someone saying, "I knew this would happen sooner or later. When central tele notifies that nurse that the her patient's leads are off she gets annoyed and checks on the leads in her own sweet time. They called her 3 times before this patient was found unresponsive." What do you do? Role play your action.
What is Speaking Up, Escalation or Reporting
500
You are a nurse and have administered 100 units of insulin instead of 10 units. You called a RRT where D50 was hung and at that time the crash cart was brought closer to the room. You have notified the doctor and your patient's blood sugar is now 50 and he is responding appropriately. The son comes to visit, sees the crash cart and is highly upset. He is agitated as he turns to you and says "What the heck happened to my father?" Role play this communication.
What is role-playing?
500
Everyone is focused on errors and near-misses, learning from them and figuring out how to prevent them from happening again. Attention to detail is crucial. Finding and fixing problems is everyone’s responsibility and is encouraged and supported by leadership.
What is preoccupation with failure?
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