Term
| How many pts are injured from med error/year |
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Definition
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Term
| How may deaths are caused by med error each year |
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Definition
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Term
| Why is error rate so high? |
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Definition
1. Complex processes
2. Lack of interoperability
3. Organization culture
4. System design issues |
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Term
| Rank risk reduction strategies in order of best to worst |
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Definition
1. Prevent (Best)
2. Detect
3. Mitigate (worse) |
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Term
|
Definition
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Term
|
Definition
| Moving away from performing a task the way you were taught |
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Term
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Definition
Comfort
Faded perception of risk
Time saving |
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Term
| Examples of "at-risk behaviors" (ARBS) |
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Definition
preparing more than one med at a time
1. not using two pt identifiers
2. not checking allergies before dispensing
3. not questioning out-of-norm-doses
4. not performing pt education
5. not reading system alerts |
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Term
| Ways to manage "at-risk behaviors" (ARBs) |
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Definition
1. expect them
2. teach why they are risky
3. design barriers and controls
4. remove incentives for ARBs
5. Reward healthy behviors |
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Term
| Reckless behaviors should be managed with |
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Definition
Remedial action
Punitive action |
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Term
| Define reckless behaviors |
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Definition
| knowingly and/or willing putting other at risk |
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Term
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Definition
| Failure Mode and Effects analysis |
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Term
| Is FMEA preventative or retrospective? |
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Definition
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|
Term
| Are RCAs preventative or retrospective? |
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Definition
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Term
| A proactive safety analysis that asks what-if questions is |
|
Definition
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|
Term
| A retrospective safety analysis that asks why questions is |
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Definition
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Term
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Definition
| For high risk, high volume, high cost, or problem prone processes |
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Term
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Definition
| When an actual or close-call sentinel event occurs |
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Term
|
Definition
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Term
|
Definition
| death or serious disability |
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Term
|
Definition
| medical intervention required to prevent death or serious injury |
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Term
|
Definition
| No death or disability. No medical intervention. |
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|
Term
| Which levels of adverse events require a RCA |
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Definition
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Term
| How soon must a level 1 event be reported? When must RCA be submitted? |
|
Definition
Reported within 5 days
RCA due in 60days |
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Term
| T/F an RCA typically has a single cause |
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Definition
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Term
| T/F an RCA focuses on systems and processes and not people |
|
Definition
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Term
|
Definition
1. Gather facts
2. Assemble team
3. Understand what happened
4. Identify Root cause
5. design/implement risk reduction strategies |
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|
Term
|
Definition
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|
Term
|
Definition
1.Drug storage/delivery
2. Workflow/staffing/environmental
3. Missing QCM |
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Term
| T/F Fishbone and tier diagrams are used in determining why an event occurred during a RCA |
|
Definition
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Term
| What must be included in step 5 of an RCA (Risk reduction strategies)? |
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Definition
1.Action plan
2. Time line
3. identify who will monitor the implementation
4. Leadership support
5. Communicate lessons learned |
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