Just Culture
A Just Culture encourages staff to do this
Report safety problems
This is what SBAR stands for
Situation, Background, Assessment, Recommendation
Complete, Clear, Brief and Timely are the four standards of this type of communication
Effective
Designated and situational are the two types of these
Leaders
This is the third leading cause of death in the US
Medical Errors
This is the percentage of patient safety events that are caused by system/process failures
90%
This rule empowers team members to "stop the line" if a safety breach is sensed
Two-Challenge Rule
To communicate critical information to all team members simultaneously is the purpose of this communication tool
Call-Out
This tool is used to regain situational awareness and address emerging issues
Huddle
This tool is used to report patient safety events
JPSR
The primary focus of a Just Culture looks at these instead of blaming the person
Process
Describe, Express, Specify and Consequences (DESC for short) is used for this
Conflict resolution
This is a closed-loop communication strategy to verify and validate information exchanged
Check-Back
This tool is used to review team performance and improve outcomes.
Debrief
These people are responsible to report patient safety events
Everyone
This is a choice to ignore safety precautions
Reckless / Risky behavior
This is used to plan and prepare the team for the day or task
Brief
Communication failures are the leading cause of this type of event measured by The Joint Commission
Sentinel Event
The main function of this person is to keep the focus of the team on the main goal
Leader
A patient safety report should be made ______ after an event is discovered
Immediately
This is the main goal of a Just Culture
To learn from mistakes and improve safety
This tool is used to quickly address problems or changes in a plan
Huddle
This type of transfer of information is used during transitions in care
Hand-off
Assigning roles during this is used to make sure everyone knows their responsibilities
Brief
This is the type of event occurs when staff or processes catch an error prior to reaching the patient
Near Miss