Science Quiz / leadership exam 1/ PATIENT SAFETY

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Can you name the leadership exam 1?

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failure of planned action to be completed as intended
culture where individual blamed, disciplinary actions, lead to underreporting of incidents
leads to reporting unsafe conditions, changes are made so the focus is on the problem itself not on the person, however still considers the person
individual practitioners should not be held accountable for system failing but does not tolerate conscious disregard of clear risks to patients or gross misconduct
is a method of problem solving used for identifying the root causes of faults or problems
Taxonomy of error root cause analysis & practice - purpose to differentiate what was related to practice vs what was related to the system
Takes into accounts the prevention strategies like surgical checklists etc.
Types of error include (3)
errors related to organizational issues- outdated policies, understaffed
errors related to direct patient care, contact
errors related to management, how organization is run from top down, priorities, resources, etc..
error due to deviation in the pattern of a routine activity such as an interruption
error due to the nurse not having the knowledge to provide the safest care
error due to conscious decision of the nurse to take short cuts
IOM recommends this bc it has functions that make it hard or impossible to do the wrong thing; like pharmacy mixing drugs instead of nurses doing it on the nurses
IOM recommends to NOT rely on _____ and instead to standardize and simplify procedures
IOM says to use ____ and _____ to increase vigilence
IOM also recommends addressing work hours, workloads and staffing ratios which is a part of work _____
Safe, timely, effective, efficient, equitable, patient centered
an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Ex: wrong site events, wrong procedure, med errors, criminal events
visual representation of the relationship among concepts and ideas - relationships among the patient's problems
may not involve a problem, always involves making a choice
involves diagnosing a problem and solving it, may or may not require a decision
type of decision making where relates to everyday situations
type of decision making that is a modification of other solutions
decision making condition where the alternative solutions and conditions are known
decision making condition where most decisions are made with some uncertainty
likelihood that an event will or will not occur based on facts and reliable information
the likelihood that an event will or will not occur based on personal judgement and beliefs
identifies all probable outcomes, examines the probabilities of each alternative, take the action that yields the highest probability of achieving the most desirable outcome
emphasizes limitations of decision maker and the situation - limits of time, energy, money etc.
the decision maker chooses an alternative that is not the best but it's good enough or the first acceptable alternative - not the best way
decisions based on the interests of powerful people in the organization.
group members meet and generate many diverse ideas about the nature, cause, definition, or solution to a problem, lots of ideas as quickly as possible
high cost factor, time consuming, superficiality of many solutions
applying one solution after another until the problem is solved or appears to be improving
involves testing a theory or a hunch- project or study is carried out in either a controlled or uncontrolled setting
an individual's experience can determine how much risk he or she will take in present circumstances

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Created Feb 25, 2017ReportFavoriteNominate

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