PHAR 464 FINAL EXAM QUESTIONS
WITH VERIFIED ANSWERS
\.what are active failures? - ANSWERS✔-1. "sharp end of the error"
2. slips, lapses, mistakes, violations
\.what are latent failures? - ANSWERS✔-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? - ANSWERS✔-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? - ANSWERS✔-1. focuses on latent
system failures
2. add layers of swiss cheese
3. close holes in swiss cheese
\.how to manage at-risk behaviors? - ANSWERS✔-1. remove rewards for risky
behavior
, 2. create incentives for safe behavior
3. increase mindfulness
\.what is Root Cause Analysis (RCA)? - ANSWERS✔-a systematic process utilized to
determine the PRIMARY cause of system failures
\.what is a root cause? - ANSWERS✔-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? - ANSWERS✔-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)? - ANSWERS✔-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 - ANSWERS✔-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
WITH VERIFIED ANSWERS
\.what are active failures? - ANSWERS✔-1. "sharp end of the error"
2. slips, lapses, mistakes, violations
\.what are latent failures? - ANSWERS✔-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? - ANSWERS✔-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? - ANSWERS✔-1. focuses on latent
system failures
2. add layers of swiss cheese
3. close holes in swiss cheese
\.how to manage at-risk behaviors? - ANSWERS✔-1. remove rewards for risky
behavior
, 2. create incentives for safe behavior
3. increase mindfulness
\.what is Root Cause Analysis (RCA)? - ANSWERS✔-a systematic process utilized to
determine the PRIMARY cause of system failures
\.what is a root cause? - ANSWERS✔-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? - ANSWERS✔-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)? - ANSWERS✔-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 - ANSWERS✔-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
