NMNC 1110 exam 2
· Blunt versus sharp errors - correct answer-o Along with types of error, the placement of
errors may be described as active (sharp end) or latent (blunt end). active errors are made
by those providers who are providing patient care, responding to patient needs at the "sharp
end," which is at the point of care. Latent conditions are the potential contributing factors that
are hidden and lie inactive in the health care delivery system, originating at more remote
aspects of the health care system, far removed from the active end. A latent failure is a flaw
in a system that does not immediately lead to an accident but establishes a situation in
which a triggering event may lead to an error.
· Characteristics of a root cause analysis (RC) ] - correct answer-o NOTICE: What
happened? (Identify the incident)
o INTERPRET: Why did it happen? (Organize a team, study the work processes, collect the
facts, search for causes)
o RESPOND: What can be done to prevent it from happening again? (Take action)
o REFLECT: Improve decision making in the future
o •A structured method used to analyze adverse events or near misses (i.e. "good catches")
o • Identify active errors
o •Uncover latent errors
o •Avoid undue focus on individual mistakes
o •Developed by engineers for manufacturing. Now widely used across industries, including
healthcare.
· Characteristics of Cultures of Safety - correct answer-o New theories and frameworks
inform current applications of safety science that describe how errors and near misses are
recognized and reported, ways to manage the myriad of human factors that impact safe care
delivery, and competencies required for health professionals to work in cultures of safety
o The safety culture of an organization is the product of individual and group values,
attitudes, perceptions, competencies, and patterns of behavior that determine the
commitment to, and the style and proficiency of, an organization's health and safety
management.
- psychological safety
- accountability
- negotiation
- teamwork and collaboration
· Current strategies to minimize errors - correct answer-o FOLLOW SAFETY PROTOCOL,
SPEAK-UP, LISTEN, TAKE CARE OF YOURSELF, DEVELOP CHECKLISTS, TEAMWORK,
PRACTICE SIMULATION, ESTABLISH A SAFETY CULTURE
· High Reliability Organizations - correct answer-o High reliability organizations (HROs)
manage work that involves hazardous environments (e.g., nuclear power plants and air
traffic control agencies) in which the consequence of errors is high but the occurrence of
error is low. AHRQ offers resources for hospitals or other organizations to adapt and apply
, the principles and characteristics of HROs. Five characteristics describe the mindset of
HROs:
§ • HROs exhibit sensitivity to operations. Beyond policies and manuals, there is a
"situational awareness" among HROs in which process anomalies and outliers are quickly
identified. Sensitivity to operations both reduces the number of errors and facilitates prompt
recognition to avoid larger consequences from errors. •
§ HROs are preoccupied with failure and focused on predicting and eliminating errors rather
than being in the position of reacting to errors. HROs view near misses as opportunities to
improve current systems by examining strengths and weaknesses and addressing gaps. •
§ HROs have a reluctance to simplify. These high-functioning organizations accept the
complexity inherent in their work and do not accept simplistic solutions for challenges
intrinsic to complex systems. In complex work environments, different team members may
have information at different times. •
§ Effective HROs exhibit deference to expertise and cultivate a culture in which team
members and organizational leaders defer to the person with the most knowledge of the
current issue or concern. The team member with the most information may not be the
individual with the highest rank, deemphasizing hierarchy. •
§ HROs exhibit a commitment to reliance. HROs pay close attention to their ability to quickly
contain errors and return to functioning despite setbacks
· Just Culture elements - correct answer-o Data about errors have not always been
accessible to health care professionals or to health care consumers. To create a culture of
safety, adverse events must be reported so they can be analyzed for lessons learned and
new procedures drafted to improve the system. "Just culture" refers to a system's explicit
value of reporting errors without punishment. A just culture is one in which people can report
mistakes or errors without reprisal or personal risk.29 Just culture does not mean individuals
are not accountable for their actions or practice, but it does mean that people are not
punished for flawed systems. A just culture promotes sharing and disclosure among
stakeholders
o We moved to just culture to emphasize that if someone breaks a rule knowingly and
willingly, then, yes, they should be disciplined and removed from an organization, but we
won't blame people for systems problems. So that's really the emphasis of a just culture.
o The goal is to avoid the tendency to blame individuals for patient safety issues when the
error is unintentional and is usually a product of many forces and mishaps that led to the
practice breakdown. However, a just culture demands attention, repair, remediation, and
discipline of those professionals who willfully ignore their professional standards.
· Open systems - correct answer-o Healthy open systems continuously exchange feedback
with their environments, analyze that feedback, adjust internal systems as needed to
achieve the system's goals, and then transmit necessary information back out to the
environment.
o In health care, systems engineering focuses on the structures, processes, and functions of
an open living system in relation to inputs and outcomes. Constant input related to
knowledge, science, skill, repair, and redesign is needed for open systems
§ Human Factor Principles in health care settings - correct answer-o here are some
examples of situations that knowledge of human factors can help health care workers avoid:
· Blunt versus sharp errors - correct answer-o Along with types of error, the placement of
errors may be described as active (sharp end) or latent (blunt end). active errors are made
by those providers who are providing patient care, responding to patient needs at the "sharp
end," which is at the point of care. Latent conditions are the potential contributing factors that
are hidden and lie inactive in the health care delivery system, originating at more remote
aspects of the health care system, far removed from the active end. A latent failure is a flaw
in a system that does not immediately lead to an accident but establishes a situation in
which a triggering event may lead to an error.
· Characteristics of a root cause analysis (RC) ] - correct answer-o NOTICE: What
happened? (Identify the incident)
o INTERPRET: Why did it happen? (Organize a team, study the work processes, collect the
facts, search for causes)
o RESPOND: What can be done to prevent it from happening again? (Take action)
o REFLECT: Improve decision making in the future
o •A structured method used to analyze adverse events or near misses (i.e. "good catches")
o • Identify active errors
o •Uncover latent errors
o •Avoid undue focus on individual mistakes
o •Developed by engineers for manufacturing. Now widely used across industries, including
healthcare.
· Characteristics of Cultures of Safety - correct answer-o New theories and frameworks
inform current applications of safety science that describe how errors and near misses are
recognized and reported, ways to manage the myriad of human factors that impact safe care
delivery, and competencies required for health professionals to work in cultures of safety
o The safety culture of an organization is the product of individual and group values,
attitudes, perceptions, competencies, and patterns of behavior that determine the
commitment to, and the style and proficiency of, an organization's health and safety
management.
- psychological safety
- accountability
- negotiation
- teamwork and collaboration
· Current strategies to minimize errors - correct answer-o FOLLOW SAFETY PROTOCOL,
SPEAK-UP, LISTEN, TAKE CARE OF YOURSELF, DEVELOP CHECKLISTS, TEAMWORK,
PRACTICE SIMULATION, ESTABLISH A SAFETY CULTURE
· High Reliability Organizations - correct answer-o High reliability organizations (HROs)
manage work that involves hazardous environments (e.g., nuclear power plants and air
traffic control agencies) in which the consequence of errors is high but the occurrence of
error is low. AHRQ offers resources for hospitals or other organizations to adapt and apply
, the principles and characteristics of HROs. Five characteristics describe the mindset of
HROs:
§ • HROs exhibit sensitivity to operations. Beyond policies and manuals, there is a
"situational awareness" among HROs in which process anomalies and outliers are quickly
identified. Sensitivity to operations both reduces the number of errors and facilitates prompt
recognition to avoid larger consequences from errors. •
§ HROs are preoccupied with failure and focused on predicting and eliminating errors rather
than being in the position of reacting to errors. HROs view near misses as opportunities to
improve current systems by examining strengths and weaknesses and addressing gaps. •
§ HROs have a reluctance to simplify. These high-functioning organizations accept the
complexity inherent in their work and do not accept simplistic solutions for challenges
intrinsic to complex systems. In complex work environments, different team members may
have information at different times. •
§ Effective HROs exhibit deference to expertise and cultivate a culture in which team
members and organizational leaders defer to the person with the most knowledge of the
current issue or concern. The team member with the most information may not be the
individual with the highest rank, deemphasizing hierarchy. •
§ HROs exhibit a commitment to reliance. HROs pay close attention to their ability to quickly
contain errors and return to functioning despite setbacks
· Just Culture elements - correct answer-o Data about errors have not always been
accessible to health care professionals or to health care consumers. To create a culture of
safety, adverse events must be reported so they can be analyzed for lessons learned and
new procedures drafted to improve the system. "Just culture" refers to a system's explicit
value of reporting errors without punishment. A just culture is one in which people can report
mistakes or errors without reprisal or personal risk.29 Just culture does not mean individuals
are not accountable for their actions or practice, but it does mean that people are not
punished for flawed systems. A just culture promotes sharing and disclosure among
stakeholders
o We moved to just culture to emphasize that if someone breaks a rule knowingly and
willingly, then, yes, they should be disciplined and removed from an organization, but we
won't blame people for systems problems. So that's really the emphasis of a just culture.
o The goal is to avoid the tendency to blame individuals for patient safety issues when the
error is unintentional and is usually a product of many forces and mishaps that led to the
practice breakdown. However, a just culture demands attention, repair, remediation, and
discipline of those professionals who willfully ignore their professional standards.
· Open systems - correct answer-o Healthy open systems continuously exchange feedback
with their environments, analyze that feedback, adjust internal systems as needed to
achieve the system's goals, and then transmit necessary information back out to the
environment.
o In health care, systems engineering focuses on the structures, processes, and functions of
an open living system in relation to inputs and outcomes. Constant input related to
knowledge, science, skill, repair, and redesign is needed for open systems
§ Human Factor Principles in health care settings - correct answer-o here are some
examples of situations that knowledge of human factors can help health care workers avoid:
