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450 Mid Study Guide
| Question | Answer |
|---|---|
| systematic arrangement of entities in any field into categories or classes based on common characteristics such as properties, morphology, and subject matter | taxonomy |
| an event that involves damage to a defined system that disrupts the ongoing or future output of the system | accident |
| injury resulting from medical intervention | adverse event |
| inter-relationship between humans, tools, and environments they are in | human factors |
| the failure of a planned action to be completed as intended or the use of a wrong plan | error |
| observable actions commonly associated with attentional or perceptional failures | slip |
| the actions may conform exactly to the plan, but the plan is inadequate to achieve its intended outcome | mistake |
| occurs immediately, typically from front line worker | active error |
| may lie dormant in the system; errors in the design, training, or maintenance | latent error |
| degree of likelihood that a desired outcome will occur and that the care is consistent with professional knowledge | quality of care |
| minimum level or range of acceptable performance or results, or excellent levels of performance, or the range of acceptable performance or results | standard |
| set of interdependent elements interacting to achieve a common aim | system |
| organizational unit which includes a core team of health professionals, a defined population of patients, an established work process, an established environment capable of linking the rest | microsystem |
| an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof | sentinel event |
| failure to provide a healthcare service when it would have produced a favorable outcome for a patient | underuse |
| when an appropriate service has been selected by a preventable complication occurs and the patient does not receive the full potential benefit of the service | misuse |
| when a healthcare service is provided under circumstances in which its potential for harm exceeds the benefit | overuse |
| added to the social security program in 1965 that provides hospitalization insurance for the elderly and permits older americans to purchase inexpensive coverage for doctor fees and other health expenses | Medicare legislation |
| 65+ years old, people disabled and entitled to social security benefits, end-stage renal disease | Medicare conditions of participation |
| 1. decide what needs to be done, 2. decide whether to disclose, 3. decide when to disclose, 4. decide who should disclose, 5. decide to disclose, 6. decide what components to include, 7. determine proper documentation, 8. offer support to the practitioner | action if an error occurs |
| gaps in continuity of care, a process to reduce errors and harm associated with medical issues as patients transfer from one level of care to another | medication reconciliation |
| gaps in continuity of care, a plan of care and discharge instructions are sent to the receiving facility/agency, but important info may be missed | transfer of information |
| gets close to the work, gets to know people around them, seeks out new knowledge, and learns and practices QI | leader |
| budget, staff, resources, and problem-solving | manager |
| these actions require our attention only when there is a change in the flow; slip | automatic mental functioning |
| requires gathering of info and compares it to known info, slower than other types, requires increased concentration; mistake | problem-solving mental functioning |
| pattern matching, biased memory, availability heuristic, confirmation bias, overconfidence | problem-solving mode factors that play a role |
| which type of mental functioning is more likely to occur | problem-solving |
| plan: communicate new standard processes to staff; do: teach, coach, and support implementation; study: observe and reflect; act: redesign standard work as needed to increase reliability | PDSA/PDCA |
| 3 questions; aim, measure, change | MFI |
| how good do you want to be and by when | AIM |
| process and outcome measures can be used | measures |
| what will you apply | change |
| a small-scale test of the methods and procedures to be used on a larger scale; used to examine the feasibility, practicality, resources, time, and cost of a research project before the main research is conducted | pilot study |
| a selection of data from a sample of the population by use of a random process, such as a random number obtained from computers | simple random sampling |
| involves division of population into smaller subgroups | proportional stratified random sampling |
| relies on judgement of those with knowledge of process to select useful samples for learning about impact of your changes on process performance | judgement sampling |
| separation and classification of data according to specific variable, demographics, factors | stratification |
| the discussion of clinically significant facts between providers and patients about the occurrence of an adverse event that could reasonably be anticipated to result in harm in the foreseeable future | disclosure |
| tool for displaying and learning from data | run charts |
| 3 shapes used: oval->indicates start and end of a process, square->indicates activities or tasks, diamond->questions | flow charts |
| interprofessional approach denotes a deeper level of cooperation whereby professionals plan and evaluate services to patients jointly; professionals from different areas pool their knowledge to maximize the benefits of services to the patient | IDT |
| most researched and prevalent issue with patient safety | communication |
| situation, backgrounds, assessment, recommendation; a communication technique that provides a standardized framework to communicate about a patient's condition | SBAR |
| closing the loop of communication | check-back |
| team regroup to reestablish awareness and planning; team events for problem-solving and updating the plan, can be called by any team member | huddle |
| short planning session prior to start; meeting that typically includes explanation, review of info, input from team members, ensuring team members know their role | brief |
| to request or provide info, communicate important or critical info | call out |
| review of events; recounting and documentation of key events: analysis of why it occurred, what worked, what didn't work, discussion related to how we can progress from here | debrief |
| transfer of info during transitions; includes an opportunity to ask questions, clarify, and confirm | hand-off |
| I'm concerned, I'm uncomfortable, this is a safety issue | CUS |
| it is your responsibility to assertively voice a concern at least 2 times to ensure it has been heard, team member being challenged must acknowledge the concern, take a stronger course of action if necessary, utilize a supervisor or chain of command | 2 challenge |
| process for identifying contributing/causal factors that underlie variations in performance associated with adverse events or close calls | RCA |
| training/retraining, re-design | RCA outcomes |
| ID of team leader, data collection, analysis of data, development of action plan, outcomes | RCA procedure |
| medical device review (only 1% reviewed), manages VAERS (program for adverse event reporting) and MedWatch (focus on unexpected/unusual events and newly produced drugs/products) | FDA role in safety |
| performs successfully under challenging conditions with very low levels of failure, the existence of a culture of safety that is not affected by risks and challenging encounters is key | high reliability organizations (HROs) |
| components: preoccupation with avoiding errors/unsafe practices, seeking out experts to assist, learning from medical errors with willingness to adapt, prioritizing safety first | development of a culture of safety |
| published in 2000, generated an enormous response from both the medical community and the public, a widespread difference exists in the perception of medical error by physicians and the public | to err is human focus |
| before 1990s, fear of retribution, decreased reporting, work-arounds | punitive culture |
| mid 1990s, lack of accountability | blame-free culture |
| 2000s, shared accountability | just culture |
| better care, better health, lower costs | triple aim |
| thinking about how to systematically address the social determinants of health and bring that into workflows of healthcare, examining root causes not just symptoms | upstream |
| innovators: adventuresome; 2. embrace change/opinion, leaders; 3. early majority: need to see evidence before change; 4. late majority: skeptical, will try only after majority has tried it; laggards: will adopt when there is no other alternative | categories of adopters |
| 3 phase model: unfreezing->loosening attachments to current behavior/practices, change/transition->when process of change actually occurs, freezing->making sure change can continue to operate as designed | lewins |
| plan is created to carry out the processes needed to achieve a prespecified outcome; plan is implemented and data is collected and analyzed; actual outcomes are assessed against the prespecified outcomes; changes should be kept or discarded | PDSA |
| 3 levels: 1. i don't get it, 2. i don't like it, 3. i don't like you; 2/3 of changes will fail due to lack of info, neg emotional reactions, or lack of trust and confidence in the team trying to implement the change | maurers |
| 8 stages: 1. create a sense of urgency, 2. build a change team, 3. form a strategic vision, 4. communicate the vision, 5. remove barriers to change, 6. focus on short-term wins, 7. maintain momentum, 8. institute change | kotters |
| 1. strategy, 2. structure, 3. systems, 4. shared values, 5. style, 6. staff, 7. skills | mckinsey 7-s's |
| 1. define change, 2. consider employee point of view, 3. provide evidence to show the best options, 4. present change as a choice, 5. listen to employee feedback, 6. limit options, 7. solidify change with short-term wins | nudge |
| 5 stages of grief: denial, anger, bargaining, depression, acceptance; employees move through stages in any order and may repeat stages; essential to communicate and empathize | kubler ross |
| Awareness of the need to change, Desire to participate in and support the change, Knowledge on how to change, Ability to implement required skills and behaviors, Reinforcement to sustain the change | ADKRA |
| legitimate reason for meeting, discuss and debate, brainstorm, complex negotiations, building camaraderie, invite only those needed, find smallest room for increased interaction, limit distractions, keep meetings short | good meetings |
| 60 minutes, not more than 90 | meeting time limit |
| STEEEP domain, avoiding injuries to patients | safe |
| STEEEP domain, reducing waits and harmful delays | timely |
| STEEEP domain, providing services based on scientific knowledge to all who could benefit | effective |
| STEEEP domain, avoiding waste | efficient |
| STEEEP domain, providing care that does not vary in quantity | equitable |
| STEEEP domain, providing care that is respectful of and responsive to individual preferences, needs, and value | patient-centered |
| process under TQM, used to improve quality and performance, it is an ongoing performance, focus is prevention of problems and ID quality of care and delivery | continuous quality improvement (CQI) |
| aspects of the patient's experience that are important to patients and families that healthcare providers must aim to perform them consistently and reliably for every patient, every time; vision: should be in the patient's voice; aim: how good an by when | always event |
| comes form inner self, something you do to reward yourself | intrinsic motivation |
| makes us do things like reaching targets before the deadline to receive an incentive or learning a new course to get promoted faster | extrinsic motivation |
| indicates that someone has sustained injury or loss as a result of an act or failure of another to act where the law has imposed a duty | tort law |
| failure to exercise the degree of skill and care that is the standard of the professional community | negligence |
| elderly, children, disabled | vulnerable groups |
| facilitates the decision-making process by considering the decision in the context of a hierarchy, with the goal at the top, criteria at the second level, subcriteria at lower levels, and alternatives at the lowest level of the hierarchy | analytic hierarchy process (AHP) |
| C of safety culture, understanding the problem, mutual comprehension is necessary, also has to be understanding of what is causing the problem and how each person/professional fits into the picture | comprehension |
| C of safety culture, non-punitive culture, being emotionally open to change, necessary when change is needed | compassion |
| C of safety culture, staff must feel psychological safety to bring problems forward | collaboration |
| C of safety culture, standardization in data, terminology, and process to minimize errors caused by miscommunication | coordination |
| C of safety culture, teamwork for safety must be the new norm | convergence |
| skill-based and is unconscious, rapid, and effortless | schematic control |
| predicated on a series of actions: if x, then y | rule-based |
| knowledge-based and requires novel problem-solving | attention control |
| proposes that some accidents are truly the product of the system and that any attempt to identify a specific cause or blame and individuals are misguided and unnecessary | normal accident theory |
| mission is to continuously improve the safety and quality of care provided, philosophy is that accreditation is a risk-reducing activity | joint commission |
| for any adverse event or close call, for all JCAHO designated sentinel events | when is an RCA done |
| intentionally unsafe acts, criminal acts, situations involving alcohol/substance abuse by employees, alleged or sustained patient abuse | when not to do an RCA |
| focus on designing in safety for all staff rather than modifying an individual's performance, moves beyond blame, makes safety a real priority through the strength of actions taken and outcomes measured | why is an RCA important |
| builds enthusiasm and understanding the need for change by building a checklist that serves as a guide | Kotter's use |
| not designed to be addressed in a specific order but rather assessed by how they affect each other so weaknesses can be identified; first 3 are "hard" elements; last 4 are "soft" elements | McKinsey's use |
| allows employees to see the need for change for themselves and influence how it is made, making resistance less likely | Nudge's use |
| limits resistance and this speeds up implementation; values employees with a mandate for change, you start a conversation to make employees aware of the need for change so that you can convince them that they will benefit from it | ADKAR change management |
| intrinsic: top half of the pyramid where highest needs reside (self-esteem, sense of achievement, feeling of belonging), extrinsic: bottom half of the pyramid with existential and worldly things (glory, pleasure, and security) | Maslow/s hierarchy of motivation |
Created by:
emma.scarmon-coyotes
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