MHA 705 M6 Exam 100% Solved
suggests that teamwork training, executive walk-arounds, and unit-based safety
Agency for Healthcare Research and
teams have improved safety culture perceptions, but have not demonstrated a
Quality (AHRQ)
significant reduction in error rates
1. Acknowledgment of the high-risk nature of an organization's activities and
thedetermination to achieve consistently safe operations
2. A blame-free environment where individuals are able to report errors or near
misses without fear of reprimand or punishment
Key features of a safety culture:
3. Encouragement of collaboration across ranks and disciplines to seek solutions to
patient safety problems
4. Organizational commitment of resources to address safety concerns
a systematic, proactive method for evaluating a process to identify where and how it
Failure Modes and Effects Analysis (FMEA) might fail, and to assess the relative impact of different failures in order to identify
the parts of the process that are most in need of change
- Blame-free environment to encourage error reporting
- System or process issues that lead to unsafe behaviors and errors are addressed by
What Is a Just Culture?
changing practices or workflows/processes.
- Clear message is communicated that reckless behaviors are not tolerated.
1.Human error (unintentional mistakes) - Perform FMEA to understand error
2. Risky behaviors (workarounds or cutting corners) - Examine workflow; educate
Just Culture error types:
3. Reckless behavior (total disregard for established policies and procedures) - Enact
zero tolerance policy; disciplinary measures
, AHRQ suggests that____________ , teamwork training
__________________, and_____________ have executive walk-arounds
improved safety culture perceptions, but unit-based safety teams
have not demonstrated a significant
reduction in error rates.
IHI strategies include____________, - appointing a safety champion for every unit
__________________, and_____________ to better - creating an adverse event response team
understand the organizational or - reenacting or simulating adverse events
procedural processes that failed
The discipline of applying what is known about human capabilities and limitations to
Human Factors Engineering
the design of products, processes, systems, and work environments
ease of use
system performance and reliability
user satisfaction
Human factors engineering improves
_______________, _______________, and _______________ Reduces:
while reducing _______________,_________ , operational errors
_______________, _______________ and_________ _. operator stress
training requirements
user fatigue
product liability
Occurs when nurses become desensitized to patient care alarms and then miss or
delay response to an alarm
Alarm fatigue
- Medical equipment alarms frequently and inappropriately
- May be related to the sensitivity of alarm parameters
- Improve the patient call system by adding voice over Internet protocol (VOIP)
phones
Strategies to improve alarm response - Feed alarm data into a reporting database for further analysis
- Encourage healthcare professionals to round with physicians to provide input into
alarm parameters
Improve communication
Reduce errors and adverse events
Increase the rapidity of response to adverse events
Informatics Technologies and Safety
Make knowledge more accessible to clinicians
Assist with decisions: technology based forcing functions that direct or restrict
actions or orders implemented by computer technologies.
Provide feedback on performance
- Wrong site surgery
- Hospital acquired infections
The National Patient Safety Foundation - Falls
(NPSF) top patient safety issues: - Hospital readmissions
- Diagnostic error
- Medication errors
Many of these issues can be prevented or informatics technologies
early detected using:
suggests that teamwork training, executive walk-arounds, and unit-based safety
Agency for Healthcare Research and
teams have improved safety culture perceptions, but have not demonstrated a
Quality (AHRQ)
significant reduction in error rates
1. Acknowledgment of the high-risk nature of an organization's activities and
thedetermination to achieve consistently safe operations
2. A blame-free environment where individuals are able to report errors or near
misses without fear of reprimand or punishment
Key features of a safety culture:
3. Encouragement of collaboration across ranks and disciplines to seek solutions to
patient safety problems
4. Organizational commitment of resources to address safety concerns
a systematic, proactive method for evaluating a process to identify where and how it
Failure Modes and Effects Analysis (FMEA) might fail, and to assess the relative impact of different failures in order to identify
the parts of the process that are most in need of change
- Blame-free environment to encourage error reporting
- System or process issues that lead to unsafe behaviors and errors are addressed by
What Is a Just Culture?
changing practices or workflows/processes.
- Clear message is communicated that reckless behaviors are not tolerated.
1.Human error (unintentional mistakes) - Perform FMEA to understand error
2. Risky behaviors (workarounds or cutting corners) - Examine workflow; educate
Just Culture error types:
3. Reckless behavior (total disregard for established policies and procedures) - Enact
zero tolerance policy; disciplinary measures
, AHRQ suggests that____________ , teamwork training
__________________, and_____________ have executive walk-arounds
improved safety culture perceptions, but unit-based safety teams
have not demonstrated a significant
reduction in error rates.
IHI strategies include____________, - appointing a safety champion for every unit
__________________, and_____________ to better - creating an adverse event response team
understand the organizational or - reenacting or simulating adverse events
procedural processes that failed
The discipline of applying what is known about human capabilities and limitations to
Human Factors Engineering
the design of products, processes, systems, and work environments
ease of use
system performance and reliability
user satisfaction
Human factors engineering improves
_______________, _______________, and _______________ Reduces:
while reducing _______________,_________ , operational errors
_______________, _______________ and_________ _. operator stress
training requirements
user fatigue
product liability
Occurs when nurses become desensitized to patient care alarms and then miss or
delay response to an alarm
Alarm fatigue
- Medical equipment alarms frequently and inappropriately
- May be related to the sensitivity of alarm parameters
- Improve the patient call system by adding voice over Internet protocol (VOIP)
phones
Strategies to improve alarm response - Feed alarm data into a reporting database for further analysis
- Encourage healthcare professionals to round with physicians to provide input into
alarm parameters
Improve communication
Reduce errors and adverse events
Increase the rapidity of response to adverse events
Informatics Technologies and Safety
Make knowledge more accessible to clinicians
Assist with decisions: technology based forcing functions that direct or restrict
actions or orders implemented by computer technologies.
Provide feedback on performance
- Wrong site surgery
- Hospital acquired infections
The National Patient Safety Foundation - Falls
(NPSF) top patient safety issues: - Hospital readmissions
- Diagnostic error
- Medication errors
Many of these issues can be prevented or informatics technologies
early detected using:
