Improve or Die
The six dimensions of high-quality healthcare are...
What are safe, effective, patient centered, timely, efficient, equitable?
That four-step process set by the Institue for Healthcare Improvement (remember that assignment we made plans to get better at something?)
What is PDSA - Plan, Do, Study, Act?
A 'It's not me, its' you' series of unfortunate events that caused a patient harm that resulted from medical care not an underlying condition.
What is Adverse Events?
What is Internal: Limited memory capacity, fatigue, stress, hunger, illness, language limitations, hazardous attitudes?
What is External: Noise, heat, light, long shifts, inadequate training, poorly designed rules/procedures, interruptions & distractions?
What is Adverse Drug Event?
It's not polite to play the blame game but if you work in quality assurance and you're also upper management then you get the honorary position of finger pointing.
What is determining fault?
The point of performance measures is sometimes because 'those guys' made me do it... because I want their money... and they won't give me money until I do it. Who are 'those guys?'
The word here kinda looks like amoeba, which describes an instance where an event could NOT have been preventable but could have been less harmful if you actually cared.
What is Ameliorable Adverse Events?
There are 10 'traps' that contribute errors - name me five and get the points!
What is time pressure, distractive environment, high workload, first time evolution, first working day after a days off, 30 minutes after wake up or a meal, vague/incorrect guidance, over-confidence, poor communication, work stress?
Oh, I didn't expect, intend, desire, or want to respond that excessively to a medication. Better put that on my allergy list.
What is an Adverse Drug Reaction?
Name me this QI Model and its' mantra that shares a name with the popular anime Jujutsu Kaisen.
What is Kaizen?
Mantra: "go to gemba"
Focus on "go to the workplace" to observe production to make improvements.
Name me the term that sounds like bench-warming but is actually a way to compare your apples to another organization's apples.
What is Benchmarking?
We say this when two semi-trucks, one of Coca-Cola and one of Mentos topple over and just barely miss each other by a few tiny millimeters - the result of pure luck or the driver's attempt to prevent the end of the world.
What is Near Miss?
There are 5 Rights implemented by the ISMP. Name them.
What is the right patient, right drug, right dose, right route, right time?
The preventable event that will keep even the least ethical pharmacist up at night - an event that can lead to inappropriate med use or patient harm.
What is Medication Error?
A QI strategy made by the Toyota Production System, adapted to healthcare focused on observation and what?
What is eliminate waste?
Focus on process of work, output is identical every time.
The 80/20 rule is seen across many different fields like retail workers are 80% bitter and 20% motivated to murder - but here it shows most problems stem from a few causes. What is this chart called?
What is the Pareto Chart?
This is a sub-term referring to doing something wrong - and if you say error - then you're wrong.
What is act of commission?
For the most part there's just bad systems, not bad people (up for debate) - to describe this James Reason developed what model to demonstrate gaps leading to harm?
What is the Swiss Cheese Model?
This Index categorizes Medication Errors - and it rhymes with slurp.
What is NCC MERP Index?
Six standard deviations from the mean and the nearest specification limit... aka reduction in variation, eliminate the defects!
What is Six Sigma?
The fishbones that help identify and organize factors that might contribute to a problem.
What is a cause-and-effect diagram?
It's more than an error to fail to do the right thing - it exposes patients to a potentially hazardous situation unnecessarily.
What is Omission?
Pharmacist's priority number 1 - preventing medication errors. There are many types - name me the overarching term for med errors.
What is Medication Misadventures?
Med Error Category I
What is an error that may have contributed or resulted in a patient's death?