Why Hospitals Fly
In “Why Hospitals Should Fly,” what are the most consistent producers of human medical error? (3 total)
Perception, assumption, and communication
What do pilots ask/do to ensure a mistake is not made?
–They read it back to make sure the communication/message they received is accurate. If needed, they can ask them to rephrase/clarify what they mean or slow down
What is an essential aspect of the perfect model of safety?
Open communication
What stage of conflict is the following scenario: verbalizations, snide remarks, statements of discomfort, cynicism or outright negative assessments
This is the symptomatic stage of conflict. It is an earlier stage of conflict and should be addressed early on to prevent further escalation of conflict
True or False: Most conflict involves differences that result in passionate position-taking and vitriol, moving human behavior into dangerous modes of expression
False; most conflict operates at a less intense level
What mistake was made resulting in tragedy and loss of a young girl at Duke University Hospital? Hint: it involved a heart-lung transplant
There was a breakdown in communication and the assumption was made that someone had checked to ensure blood-types matched
How can nurses implement aviation practices into healthcare to reduce errors?
Read-back the order/message from the doctor, nurse or physician to ensure accuracy and patient safety
What is done in the OR to ensure patient safety before a surgical procedure is started?
“Time-out.” The surgical team runs through a checklist of every item after the patient is sedated but before starting the procedure. This includes: if the vital sign machine is actually working/showing the vitals, if various gauges for the anesthesiologist is working, etc.
True or False: Early detection of mistakes is positively affected when the environment lacks openness and honesty?
False; it negatively affects early detection of mistakes
List the usual and ordinary conflict sources:
Mixture of personalities; personal needs, insights and requisites; continuously unresolved issues; and issues of workload, work distribution, and workload intensity
What is the hard-and-fast rule and how does it apply to error?
With this rule, if a nurse or pharmacist cannot read/interpret with absolute certainty what a physician has ordered, then the physician must be contacted immediately for clarification. Doing this helps to reduce assumptions, and incorrect interventions that could otherwise result in injury or death for the patient
What is the authors explanation for why he calls the healthcare system backwards in need of rewiring?
Because in American healthcare hospitals do not get paid for keeping people well and curing them fast.
True or False: 12.5% of the time, humans do not understand what they’re saying to one another.
True; Add other disruptions and this % increases
What is an essential aspect of the work environment that must be present in order for conflict to be dealt with?
Trust
True or False: Early engagement of conflict is valuable under all circumstances?
True
What was the overall message of the video from Chapter 9 of “Why Hospitals Fly?” This concept was also seen in the example of the nurse presenting research on hydrogen peroxide to the physician?
First do not harm. The physician harmed the patient to make a point by pouring the entire bottle of peroxide on the wound while having the nurse observe.
True or False: If it can be misread, misunderstood, misinterpreted, misquantifiedor just plain missed, will it be?
Yes. The nurse should always assume the worst and expect that mistakes will occur if any bit of possibility is there. By assuming this, the nurse can instead be more careful and utilize the systems set in place to specifically neutralize such errors before they may occur.
True or False: Changes should not be made without involving the group
True, operating as a team and agreeing together to make a change is important. If there is a break in the chain of safety, the procedure/intervention may not without certainty, work.
True or False: Most conflict is resolvable?
True; 90% is completely solvable
True or False: Before a leader can engage in resolving conflict, he/she must first be comfortable with his/her own sense of comfort in the presence of conflict?
True; It is hard to ask others to be comfortable in the presence of conflict if the leaders own behaviors exemplifies discomfort with the passion, emotions, noise, and expressions of conflict
Allowing cell phones (or in past years, newspapers) into the OR is dangerous and an example of ___ and can lead to ___?
A small deviation that can lead to normalization of deviance
True or False: Conflict has an accelerating pace. It always grows in intensity over time and becomes more and more complicated?
True!
The 1st manifestation of early conflict is?
A situational clash between 2 individuals that reflects differences in view, opinion, role, relationship, situation or incident