Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
32 Cards in this Set
- Front
- Back
|
A complex framework of national, organizational, and professional attitudes and values within which groups and individuals function
|
Culture
|
|
|
Culture embodies the philosophies of senior leaders and affects ____________.
|
Affects the behaviors of employees
|
|
|
What are some Highly Reliable Organizations? Is healthcare included?
|
aviation, chemical manufacturing, nuclear power production, military
Healthcare is not reliable |
|
|
What makes organizations Highly Reliable?
|
Consider safety
|
|
|
Culture in healthcare
|
differs than culture in “highly reliable” industries
personal responsibility non-creative does not commit to continual safety improvements silos |
|
|
What are some values of highly reliable organizations?
|
interpersonal responsibility
coworkers helpful and supportive of one another friendly, open, sensitive personal relations creativity pride in achieving goals strong feelings of credibility strong feelings of interpersonal trust resiliency |
|
|
Why is healthcare not highly reliable?
|
Why?
competing demands for attention process stagnation required to do more with less funding rush to be efficient sacrifice reliability |
|
|
What is an Ineffective Approach to Medication Error Prevention?
|
Naming blaming, shaming and
training |
|
|
What are some New Approaches to Error Reduction ?
|
Focus attention on the most manageable component of an error THE SYSTEM
Redefine accountability and directs it in a productive and useful manner Make MORE people MORE accountable |
|
|
Effective Approaches to Medication Error Prevention
|
Proactive not reactive
Promotes open communication about errors Shared accountability |
|
|
Key concepts in safeguarding high alert medications
|
Simplify - reduce steps and number of options
Externalize or centralize error prone processes Differentiate items (appearance, location) Differentiate items (touch, color, smell, etc.) Standardize (communication and dosing methods) Redundancy (check systems, back-ups) |
|
|
inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. (consoled)
|
human error
|
|
|
behavioral choice to consciously disregard a substantial and unjustifiable risk. Threat to society? (disciplinary)
|
Reckless behavior
|
|
|
behavior that increases risk where risk is not recognized, or is mistakenly believed to be justified. (coaching)
|
At-risk behavior
|
|
|
WHich type of behavior should be punished?
|
reckless behavior
|
|
|
The Three Behaviors
|
human error, at risk behavior, and reckless behavior
|
|
|
failure of a planned sequence of mental or physical activities to achieve its intended outcome
|
Error
|
|
|
observable
Reached for wrong drug because of labeling |
Slips
|
|
|
not observable
Couldn’t remember which drug to pick |
Lapses
|
|
|
fair treatment of workers involved in errors, REGARDLESS OF OUTCOME
|
Just culture
|
|
|
actions that proceed as planned but fails to achieve its intended outcome because the planned action was wrong
|
Mistakes
|
|
|
Human error is managed through?
|
process and procedure changes
education design environment |
|
|
behavioral choices that increases risk where risk is not recognized, or is mistakenly believed to be justified
|
At-risk behavior
|
|
|
At-risk behavior manager managed through
|
removing pressures that often lead people to cut corners
recognition that it is just by chance that more serious mistakes don’t happen here changing the way repetitive problems are addressed |
|
|
At-risk behavior individuals managed through
|
recognition of behavior
changing perceptions of risk and consequences |
|
|
behavioral choice to consciously disregard a substantial and unjustifiable risk; the worker:
|
Reckless behavior
|
|
|
Reckless behavior managed through
|
remedial or disciplinary actions
|
|
|
managed through remedial or disciplinary actions
|
Reckless behavior
|
|
|
Most errors result from complexity of healthcare system and not individual recklessness or incompetence
|
True
|
|
|
Most common error type in New Prescriptions
|
Wrong instructions
|
|
|
most common Error Types in Refill and Other Prescriptions
|
wrong quantity or strngth
|
|
|
When you look at the different phases of medication use, errors occur predominantly during the
|
prescribing (39%) and administration (38%) phases
|
