Reliability
Human Error Types
Situational Awareness
Event Analysis
Safety Behaviors
100
The collective product of individual and group values and attitudes, competencies, and patterns of behaviors in safety performance.
What is a "culture of safety?"
100
An error occurred because the person was in a new or novel situation and lacked understanding of the complexities at hand.
What is a knowledge based error/
100
Undivided attention and awareness on the present
What is "mindfulness?"
100
This is the primary purpose of a Cause Map conversation.
What is understanding the event well enough to prevent its recurrence?
100
Use 2 patient identifiers for patient identification, every time; Participate in a time out process before surgical procedures; use a second verifier prior to the administration of blood products or high risk medications.
What is a MH Red Rule?
200
This is a characteristic of a reliable organization and often leads to disclosure and apology after a medical harm.
What is openness and transparency?
200
One of the biggest benefits cause mapping brings to an organization
What is maximizing learning across the organization?
200
Situational awareness is negative impacted by...
What is Multi-tasking, Fatigue, Distractions, Excessive Noise, Bias, Production Pressures, Overconfidence and etc.
200
A review of all of the things that could go wrong before the implementation of a new process so that potential failures can be addressed by "tweaking" the process to make it safer.
What is a "Failure Modes and Effect Analysis (FMEA)"?
200
S-T-A-R
What is Stop, Think, Act and Review
300
An atmosphere in which healthcare workers can report actual or potential errors, events, and hazards without fear of reprisal.
What is a environment of event reporting?
300
An error related to an action that takes little attention because the action is done frequently as part of a routine.
What is a skill-based error?
What is a slip or lapse?
300
The most successful safety behavior to improve situation awareness is...
What is Top-Think-Act-Review (STAR)
300
This is a review of a number of events to analyze for trends, common causation and cause and effect relationships.
What is a common cause analysis?
300
The sender of the communication communicates the message, the receiver then verifies the message heard and finally, the sender verifies that the message was heard correctly.
What is 3-way communication?
400
This undermines a culture of safety and has a negative effect on the communication and collaboration necessary for safe patient care.
What is disruptive behavior?
400
An error that occurs because the wrong process or protocol was use in the situation or because shortcuts were taken.
What is a rule based error.
400
A one second pause to validate and become more situationally aware decreases the chance of error by this number...
10,000
400
This picture represents
What is the Swiss Cheese Model by James Reason?
400
A preoccupation that failure is a possibility in this highly technical, chaotic environment and without attention to this fact, error is more likely.
What is a "questioning attitude?"
500
Leadership whose actions and behaviors include promoting open communication about safety concerns, educating staff about safety science, empowering staff to identify and ameliorate hazards and risks, advocating safety as everyone’s responsibility, and allocating adequate safety resources leads to this...
What is a culture of safety?
500
After achieving 97% scanning compliance attention moved to another safety initiative and compliance dropped to 92%.
What is "Drift?"
500
This type of error does not happen less often with additional education or asking an employee to re-read the policy or procedure.
What is a skill based error?
500
Estimates are that compliance is 45-70%, thus making this the biggest reason a Cause Map fails to prevent recurrence.
What is the Corrective Action Plan or Corrective Action Plan to Prevent Recurrence (CATPR)?
500
When an unsafe patient situation is identified and the usual action fails to provide a safety solution the employee must...
Escalate the situation using the chain of command
Utilize the MH Escalation P&P.
Stop the Line and escalate.