Quality And Safety

Front 1

Which system collects data on error for internal and external monitoring

Back 1

Event reporting system

Front 2

Human factor design component

Back 2

1- Checklist

2- Electronic medical records

3- Verifying patients identification prior to procedures

Front 3

Clinical pathways, guideline and checklist are examples of what type of human factor design

Back 3

Standardization

Improve process reliability

Front 4

Electrical medical records are what type of human factor design

Back 4

Simplification

To reduce wasteful activity

Front 5

PDSA cycle

Back 5

Plan - Define problem and solution

Do- Test new process

Study - measure and analyze data

Act - integrate new process into workflow

Front 6

Function of the PDSA model

Back 6

Process improvement model to test changes

Front 7

Quality measurements

Back 7

1- Structural - physical equipment, resources and faculty

2- Process - Performance of system as planned

3- Outcome - Impact on patients

4- Balancing - Impact on other system and outcome

Front 8

Swiss cheese model

Back 8

Prevent harm in the system however harm can occur when the holes line up

Front 9

Types of medical errors

Back 9

Active error

Latent error

Never events

Near misses

Front 10

Active error

Back 10

1- Occur at the level of frontline operator

2- Immediate effect

Front 11

Latent Error

Back 11

1- Occur in the process indirectly from the operator

2- Impact on patients care

3- Accident waiting to happen

Front 12

Never events

Back 12

1- Adverse events that are identifiable serious and usually preventable

2- Must never happen

Front 13

Near miss

Back 13

Error does not harm the patient

Front 14

Burn out

Back 14

1- Stress

2- Detachment/ Depersonalization

3- Lack of fulfillment/ accomplishment

4- Lack of interest/ attention

5- Decrease immunity

6- Medical error due to lack of interest

Front 15

Fatigue

Back 15

1- Lack of energy

2- Sleep deprivation

3- Cognitive impairment

4- Medical error due to compromised intellectual function

Front 16

Medical error analysis

Back 16

Root cause analysis

Failure mode and effect analysis

Front 17

Root cause analysis

Back 17

1- Retrospective approach

2- Applied after failure to prevent occurrence

Front 18

Failure mode and effect analysis

Back 18

1- Forward looking approach

2- Applied before occurrence