HCQM UPDATED COMPREHENSIVE ALL
QUESTIONS AND ANSWERS SURE A+
✔✔Annenberg Conferences of 1996 and 1997 - ✔✔Developed an interdisciplinary
community of people including patients and professionals from outside health care
aimed at solving patient safety problems.
✔✔Examining Errors in Health Care: Developing a Prevention, Education, and
Research Agenda - ✔✔1996 Annenberg Conference
✔✔A Tale of Two Stories: Contrasting Views of Patient Safety - ✔✔2nd Annenberg
Conference 1997
✔✔1997's National Patient Safety Foundation - ✔✔Established by the American
Medical Association at the Annenberg Conference to be a catalyst for action and a
vehicle to support change and track improvements in patient safety.
✔✔1998 National Academy of Sciences Institute of Medicine (IOM) - ✔✔Charged the
Committee on Quality of Care in America with developing a strategy that will result in a
threshold improvement in quality over the next ten years.
✔✔1999 To Err is Human: Building a Safer Health System - ✔✔First report issued by
the IOM's Committee on Quality of Care in America is considered to have launched the
current patient safety movement
✔✔To Error is Human found out this about adverse events resulting from medical errors
- ✔✔More than half could have been prevented.
✔✔Number of Americans dying annually from medical errors - ✔✔44,000-98,000
, ✔✔Medical care seems to have resisted safety improvement efforts, but it is difficult to
tell based on today's statistics because - ✔✔More errors are reported than ten years
ago.
✔✔Human Factors Engineering - ✔✔Contributes to safety through understanding the
interrelationships between humans, the tools they use, and the environment in which
they live and work.
✔✔Cognitive Psychology - ✔✔Study of our mental processes
✔✔James Reason and Jens Rasmussen - ✔✔Psychologists who offered new
frameworks for thinking about human error.
✔✔Active errors - ✔✔Errors whose effects are felt almost immediately; made at the
sharp end of care by clinicians
✔✔Latent errors - ✔✔Adverse consequences may lie dormant within the system for a
long time only becoming evident when they combine with other factors to breach the
system's defenses. Made at the blunt end of care by executives, managers, equipment
manufacturers, regulators, etc.
✔✔Reason's Discover and Neutralize recommendation - ✔✔Seek out latent failures
within a system to have a greater impact on improving the system rather than engaging
in localized efforts to minimize active errors.
✔✔Swiss Cheese Model - ✔✔Reason's model used to describe a certain kind of patient
safety risk in which the potential for an error to slip through multiple defenses to reach
the patient and cause harm. Dekker states the model is too linear to well describe more
complex systems but acknowledges it helps move focus away from clinicians and
upstream.
✔✔Culture of Patient Safety - ✔✔Institutions where everyone is encouraged to speak
up when they recognize a hazardous situation or when things go wrong and then follow
up with corrective action aimed at improving the system not aimed at punishing
individuals.
✔✔Just Culture - ✔✔Developed by David Marx in 2007 to create a hierarchy of levels of
accountability for different behaviors: 1. Human error - inadvertent mistakes which
should managed by consoling the individual and making changes to processes,
procedures, training, and design 2. At risk behavior includes choices involving risk that
is not recognized or justified and should be managed by coaching the individual and
rewarding healthy behavior. 3. Reckless behavior includes conscious disregard of
unreasonable risk which should result in remedial and punitive actions. Is considered a
more appropriate evolution from the blame free environment first supported with the
advent of error transparency.
QUESTIONS AND ANSWERS SURE A+
✔✔Annenberg Conferences of 1996 and 1997 - ✔✔Developed an interdisciplinary
community of people including patients and professionals from outside health care
aimed at solving patient safety problems.
✔✔Examining Errors in Health Care: Developing a Prevention, Education, and
Research Agenda - ✔✔1996 Annenberg Conference
✔✔A Tale of Two Stories: Contrasting Views of Patient Safety - ✔✔2nd Annenberg
Conference 1997
✔✔1997's National Patient Safety Foundation - ✔✔Established by the American
Medical Association at the Annenberg Conference to be a catalyst for action and a
vehicle to support change and track improvements in patient safety.
✔✔1998 National Academy of Sciences Institute of Medicine (IOM) - ✔✔Charged the
Committee on Quality of Care in America with developing a strategy that will result in a
threshold improvement in quality over the next ten years.
✔✔1999 To Err is Human: Building a Safer Health System - ✔✔First report issued by
the IOM's Committee on Quality of Care in America is considered to have launched the
current patient safety movement
✔✔To Error is Human found out this about adverse events resulting from medical errors
- ✔✔More than half could have been prevented.
✔✔Number of Americans dying annually from medical errors - ✔✔44,000-98,000
, ✔✔Medical care seems to have resisted safety improvement efforts, but it is difficult to
tell based on today's statistics because - ✔✔More errors are reported than ten years
ago.
✔✔Human Factors Engineering - ✔✔Contributes to safety through understanding the
interrelationships between humans, the tools they use, and the environment in which
they live and work.
✔✔Cognitive Psychology - ✔✔Study of our mental processes
✔✔James Reason and Jens Rasmussen - ✔✔Psychologists who offered new
frameworks for thinking about human error.
✔✔Active errors - ✔✔Errors whose effects are felt almost immediately; made at the
sharp end of care by clinicians
✔✔Latent errors - ✔✔Adverse consequences may lie dormant within the system for a
long time only becoming evident when they combine with other factors to breach the
system's defenses. Made at the blunt end of care by executives, managers, equipment
manufacturers, regulators, etc.
✔✔Reason's Discover and Neutralize recommendation - ✔✔Seek out latent failures
within a system to have a greater impact on improving the system rather than engaging
in localized efforts to minimize active errors.
✔✔Swiss Cheese Model - ✔✔Reason's model used to describe a certain kind of patient
safety risk in which the potential for an error to slip through multiple defenses to reach
the patient and cause harm. Dekker states the model is too linear to well describe more
complex systems but acknowledges it helps move focus away from clinicians and
upstream.
✔✔Culture of Patient Safety - ✔✔Institutions where everyone is encouraged to speak
up when they recognize a hazardous situation or when things go wrong and then follow
up with corrective action aimed at improving the system not aimed at punishing
individuals.
✔✔Just Culture - ✔✔Developed by David Marx in 2007 to create a hierarchy of levels of
accountability for different behaviors: 1. Human error - inadvertent mistakes which
should managed by consoling the individual and making changes to processes,
procedures, training, and design 2. At risk behavior includes choices involving risk that
is not recognized or justified and should be managed by coaching the individual and
rewarding healthy behavior. 3. Reckless behavior includes conscious disregard of
unreasonable risk which should result in remedial and punitive actions. Is considered a
more appropriate evolution from the blame free environment first supported with the
advent of error transparency.
