Medical Error
The 3 leading causes of death in the US before the COVID-19 before the COVID-19 pandemic.
What are Heart Disease, Cancer & Medical Errors?
The disposition to judge things as being more likely, or frequently occurring, if they readily come to mind. Conversely, if a disease has not been seen for a long time, it may be under diagnosed.
What is Availability Bias?
PDSA stands for these phases of QI
What are Plan, Do, Study, Act?
“The lady with the lamp” got this nickname when she was in this country.
What is Turkey?
A positive association is a PREFERENCE and the negative association a ____.
What is BIAS?
The type of diagnostic error when a fracture was missed in the ER because a radiologist was not available.
What is Systems Error?
The tendency to be judgmental and blame patients for their illnesses (dispositional causes) rather than examine the circumstances (situational factors) that might have been responsible
What is Fundamental Attribution Error?
This QI model has 5 steps: Identify, Exploit, Subordinate, Elevate, Repeat
What is the Theory of Constraints (TOC)?
Florence Nightingale’s Rose Diagram depicted the causes of mortality of soldiers from this country.
What is Great Britain?
Two of the 6 key healthcare system dimensions described by the IOM in Crossing the Quality Chasm (2001).
What are: (any 2) Safety, Effectiveness, Timeliness, Patient-Centeredness, Efficiency, Equity?
The type of diagnostic error when the diagnosis of lung cancer was delayed by 6 months because a mass on a chest x-ray was not noticed.
What is Cognitive Error?
A tendency to believe that we know more than we do. ________reflects a tendency to act on incomplete information, intuitions or hunches. Too much faith is placed in opinion rather than carefully gathered evidence.
What is Overconfidence Bias?
Failure Modes and Effect Analysis is a common tool in this QI model/management system
What is Six Sigma?
This historical figure said “Quality is not an act, it is a habit.”
Who is Aristotle?
The year the first Healthy People was released.
What is 1980?
The main categories of cognitive error.
What are Failed perception, Associations (Bias) & Failed heuristics?
The tendency to perpetually lock onto salient features in the patient’s initial presentation too early in the diagnostic process, and failing to adjust this initial impression in light of later information.
What is Anchoring?
The Institute for Healthcare Improvement’s 3 key questions in the Model for Improvement process.
What are we trying to improve?
How will we know if we are making an improvement?
What changes can we test to make the improvement?
“The Mother of the Army”, Mary Jane Seacole was born in this country.
What is Jamaica?
Taiichi Ono used this word meaning “waste” in English as a foundational concept in his QI efforts.
What is Muda?
Five common causes of medical errors.
What are: Communication Breakdowns, Human Problems, Patient-Related Issues, Cognitive Factors (Judgement, Knowledge, Memory), Organizational Transfer of Knowledge, Staffing Patterns & Workflow, Technical Failures, Inadequate Policies ?
Information transfer is a U-function: we tend to remember the beginning part or the end.
What is Order Effects?
The 8 types of waste in LEAN.
Transportation, Inventory, Motion, Human Potential, Waiting, Overproduction, Over-processing, Defects
The chief engineer at Toyota who created a manufacturing system that focused on reducing cost by eliminating waste.
Who is Taichii Ono?
The 5 components of the Quintuple Aim.
What are the Patient Experience, Population Health, Lower Costs, Provider/Care-team Experience, Health Equity?