PS 102 Questions and Answers 100% Pass

Swiss cheese model of accident causation Serious adverse events are almost always the result of multiple failed opportunities to stop a hazard from causing harm Latent conditions defects in the design and organization of processes and systems — things like poor equipment design, inadequate training, or insufficient resources. These errors are often unrecognized, or just become accepted aspects of the work, because their effects are delayed. Active failures errors whose effects are seen and felt immediately: someone pushing an incorrect button, ignoring a warning light, or grabbing the wrong medication. Referring to the video on the previous page, which of the following factors do you think contributed to the Tenerife plane crash? The only factors that didn't contribute to the Tenerife disaster were mechanical problems and staff incompetence.The Spanish Accident Board that investigated the crash found that human error on the part of the captain was the proximal cause of the accident. Captain Van Zanten took off without clearance, and ignored several warnings that he did not have clearance — this was the active failure in the Swiss cheese event. But this accident also laid bare many latent conditions that made the system unsafe: a lack of a clear communication protocol for take-off, stress from the urgency of the take-off, and a hierarchical culture that made it difficult for the co-pilot to speak up about the error. These conditions in combination allowed the active error to occur, and lead to disaster. Which of the following would be an effective solution to help prevent the Tenerife disaster from happening again? After the Tenerife disaster, the aviation industry began to look at safety as a property of a system. Instead of blaming the individuals involved in the crash, it devised systems solutions, such as standardizing the terms to communicate about clearance and training staff to communicate openly about safety issues, regardless of hierarchy.Aviation will always exist in a hazardous environment; changing conditions in the system that allowed the hazardous environment to cause a disaster — i.e., filling the holes in the cheese (opportunities for processes to fail) and adding more slices (layers of defense) — is the best way to prevent a recurrence of the same tragedy.1 Which of the following factors makes health care dangerous to patients and providers? powerful drugs, complicated procedures, & pts who require complex care -The best answer is all of the above. As Doug Bonacum says, "For our frontline practitioners, there are always new medications, new technologies, new procedures, and new research findings to assimilate...patients are becoming increasingly complex and the diversity of the workforce grows at an increasing rate. Providing safe reliable care has never been more challenging than today."