COMPLETE QUESTIONS AND SOLUTIONS
◉ Regulator. Answer: Provide public oversight of healthcare entities
and providers
◉ Name the 6 Major Regulators of Healthcare. Answer: CMS: Sets
minimum standard for $$$
Joint Commission: Accreditation
NAM: Objective health information
NQF: Endorses national standard for science
IHI: Improvement science to advance better health outcomes
◉ Sentinel event. Answer: unexpected occurrence involving death or
serious injury (temporary or permanent)
◉ Senior Executive Adopt-a-Work Unit. Answer: pair a hospital
executive with a work unit to help them with safety issues
◉ Situational Awareness. Answer: Knowledge and understanding of
your surroundings and situation and the risk they potentially pose
to your safety
,◉ ROI equation. Answer: savings/investment x 100
◉ RPN equation. Answer: severity x likelihood of UNdetectability x
likelihood to happen
◉ what makes an RCA credible?. Answer: varied participants
internally consistent
explains "N/A" or "No problem"
◉ when to use the 5 why's. Answer: to get to the root cause
◉ Hierarchy of Improvement Strategies. Answer: Education <
Rules/Policies < Checklists < Standardization < Automation <
Forcing Function
◉ RCA Steps and Phases. Answer: Initiation Phase
ID event
Select team
Screening Phase
Describe what happened
, Analysis Phase
ID contributing factors
ID root causes
Design and implement plan
Monitoring Phase
Measure success of plan
◉ biggest pitfall of RCA. Answer: skipping chronology
◉ FMEA Steps. Answer: 1. Select team
2. ID process
3. Diagram process
4. ID failure modes and rank them
5. Determine an action plan
◉ Latent failure. Answer: 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.
i.e sleep deprivation