PHAR 464 FINAL QUESTIONS AND ANSWERS 100%
CORRECT.
what are active failures? Answer - 1. "sharp end of the error"
2. slips, lapses, mistakes, violations
what are latent failures? Answer - 1. "blunt end of errors"
2. fundamental vulnerabilities or conditions that contribute to active failures
(error provoking conditions)
3. may have dormant stage where they are not leading to errors
what is just culture? Answer - 1. don't punish when someone is involved in an
error that could affect "anybody" in the same position
2. punish gross negligence
what does the Just Culture Model focus on? Answer - 1. focuses on latent
system failures
2. add layers of swiss cheese
3. close holes in swiss cheese
how to manage at-risk behaviors? Answer - 1. remove rewards for risky
behavior
2. create incentives for safe behavior
3. increase mindfulness
, what is Root Cause Analysis (RCA)? Answer - a systematic process utilized to
determine the PRIMARY cause of system failures
what is a root cause? Answer - any identified reason in the sequence of events
that, if prevented, will stop recurrence of the particular event
-there must be a clear cause and effect
what is a sentinel event? Answer - a patient safety event (not related to
natural course of pt's illness) that reaches a patient and results in harm
What is failure mode and effects analysis (FMEA)? Answer - problem-solving
tool used to analyze a process or system to identify possible modes of failure
and potential consequences of those failures
criteria for an effective RCA process Answer - 1. define problem and
significance
2. delineate known causal relationships that combined to cause problem
3. establish causal relationships between root cause(s) and problem
4. present evidence
5. explain how solutions will prevent recurrence of problem
what is Safety Assessment Code (SAC) also called Probability/Severity Matrix
Answer - -compares severity of and probability of errors with 3 being highest
risk and 1 being lowest risk
-SAC score of 3 results in formal investigation/RCA
should an RCA only be done on sentinel events? Answer - no, it can also be
used for "near miss" events
CORRECT.
what are active failures? Answer - 1. "sharp end of the error"
2. slips, lapses, mistakes, violations
what are latent failures? Answer - 1. "blunt end of errors"
2. fundamental vulnerabilities or conditions that contribute to active failures
(error provoking conditions)
3. may have dormant stage where they are not leading to errors
what is just culture? Answer - 1. don't punish when someone is involved in an
error that could affect "anybody" in the same position
2. punish gross negligence
what does the Just Culture Model focus on? Answer - 1. focuses on latent
system failures
2. add layers of swiss cheese
3. close holes in swiss cheese
how to manage at-risk behaviors? Answer - 1. remove rewards for risky
behavior
2. create incentives for safe behavior
3. increase mindfulness
, what is Root Cause Analysis (RCA)? Answer - a systematic process utilized to
determine the PRIMARY cause of system failures
what is a root cause? Answer - any identified reason in the sequence of events
that, if prevented, will stop recurrence of the particular event
-there must be a clear cause and effect
what is a sentinel event? Answer - a patient safety event (not related to
natural course of pt's illness) that reaches a patient and results in harm
What is failure mode and effects analysis (FMEA)? Answer - problem-solving
tool used to analyze a process or system to identify possible modes of failure
and potential consequences of those failures
criteria for an effective RCA process Answer - 1. define problem and
significance
2. delineate known causal relationships that combined to cause problem
3. establish causal relationships between root cause(s) and problem
4. present evidence
5. explain how solutions will prevent recurrence of problem
what is Safety Assessment Code (SAC) also called Probability/Severity Matrix
Answer - -compares severity of and probability of errors with 3 being highest
risk and 1 being lowest risk
-SAC score of 3 results in formal investigation/RCA
should an RCA only be done on sentinel events? Answer - no, it can also be
used for "near miss" events
