IHI PS 101: Introduction to Patient Safety – Flashcards
Unlock all answers in this set
Unlock answersquestion
What is most likely to happen if a health system punishes an individual for an unintended error that was the result of a systems problem?
answer
A and C Punishing individuals for blameless errors has a weakening effect on a health system's culture of safety (an environment in which providers can discuss errors and harm openly because they know they won't be unfairly punished and have confidence that reporting safety events will lead to improvement). Staff may view the punishment as unfair, and worry that they will be punished if they make an error. This fear decreases the chances of staff reporting errors so that the system can learn from them. Staff trying to be more careful will ultimately not eliminate errors caused by faulty systems.
question
Which of the following statements is true about blame and punishment of individuals for making errors?
answer
They can be appropriate responses if that individual intentionally caused harm. There are some rare cases when it may be appropriate to blame and punish an individual who deliberately ignored protocol or intentionally caused harm. However, this is a small minority of cases. Blame and punishment can never undo or prevent errors, nor can they prevent errors from happening.
question
A colleague accesses and delivers a medication, believing it is the correct one. Unfortunately, it isn't — it is another medication in a similar vial. Which of the following is the best way to address his error?
answer
Investigate whether others find the vials confusing and consider making a change to how they are packaged or accessed. The best answer is to investigate the source of the error and consider making a change to the system, such as how the medications are packaged or accessed. Learning from an error and putting systems in place to prevent the error is the only effective way to reduce the likelihood the error will happen again.
question
When an error occurs, which of the following is a productive response?
answer
A and C A and C are productive responses to error. Determining if reasonable changes can be made to prevent the same type of error in the future is a great response after an error occurs. Note that when interviewing participants about the error, the goal should be to understand what happened — not to determine fault or place blame.
question
Which of the following situations seems to warrant punitive action?
answer
A colleague routinely refuses to perform a mandatory safety process. In rare cases, such as where protocol is deliberately being ignored, punitive action may be warranted. However, most errors are the result of unintentional situations. For instance, it's easy to be distracted in a fast-paced setting. If your colleague has made the same error more than once, it is, most likely, an easy error to make. (You may find others making it, too.) This is why we need strong systems in place to protect us.
question
Which of these is a behavior providers should adopt to improve patient safety?
answer
Follow written safety protocols, even if they slow you down
question
What would be the MOST appropriate way for the nurse to respond?
answer
Talk to the medical director now, in confidence
question
When it comes to self-care, which of the following statements is true?
answer
All of the above
question
Which of the following critical behavior(s) did Janet violate?
answer
A and C
question
Which of the following techniques represent best practice for communicating with patients and families?
answer
All of the above
