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Swiss cheese model of accident causation ✔✔Serious adverse events are almost always the result of multiple failed opportunities to stop a hazard from causing harm Latent conditions ✔✔defects in the design and organization of processes and systems — things like poor equipment design, inadequate training, or insufficient resources. These errors are often unrecognized, or just become accepted aspects of the work, because their effects are delayed. Active failures ✔✔errors whose effects are seen and felt immediately: someone pushing an incorrect button, ignoring a warning light, or grabbing the wrong medication. Referring to the video on the previous page, which of the following factors do you think contributed to the Tenerife plane crash? ✔✔The only factors that didn't contribute to the Tenerife disaster were mechanical problems and staff incompetence.The Spanish Accident Board that investigated the crash found that human error on the part of the captain was the proximal cause of the accident. Captain Van Zanten took off without clearance, and ignored several warnings that he did not have clearance — this was the active failure in the Swiss cheese event. But this accident also laid bare many latent conditions that made the system unsafe: a lack of a clear communication protocol for take-off, stress from the urgency of the take-off, and a hierarchical
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culture that made it difficult for the co-pilot to speak up about the error. These conditions in combination allowed the active error to occur, and lead to disaster. Which of the following would be an effective solution to help prevent the Tenerife disaster from happening again? ✔✔After the Tenerife disaster, the aviation industry began to look at safety as a property of a system. Instead of blaming the individuals involved in the crash, it devised systems solutions, such as standardizing the terms to communicate about clearance and training staff to communicate openly about safety issues, regardless of hierarchy.Aviation will always exist in a hazardous environment; changing conditions in the system that allowed the hazardous environment to cause a disaster — i.e., filling the holes in the cheese (opportunities for processes to fail) and adding more slices (layers of defense) — is the best way to prevent a recurrence of the same tragedy. Which of the following factors makes health care dangerous to patients and providers? ✔✔powerful drugs, complicated procedures, & pts who require complex care
- The best answer is all of the above. As Doug Bonacum says, "For our frontline practitioners, there are always new medications, new technologies, new procedures, and new research findings to assimilate...patients are becoming increasingly complex and the diversity of the workforce grows at an increasing rate. Providing safe reliable care has never been more challenging than today."
What is the active error in this scenario? ✔✔The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.
- The active error is the human error that led to patient harm. In this case, it's the nurse administering an antibiotic to Ms. Tyler and a sedative to Ms. Taylor. with extremely high blood glucose levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for "units"), and it looks more like an extra zero. As a result, the pharmacist dispenses an insulin dose that's ten times stronger than the patient needs. To prevent this problem from happening again, which of the following would be the best course of action? ✔✔Develop a system that prevents messy handwriting from causing miscommunication that leads to error. Correct Answer:Develop a system that prevents messy handwriting from causing confusion that leads to error. For example, the organization could switch to an electronic ordering system. Mandating additional training and/or punishing the resident and pharmacist for an unintentional error won't prevent them or anyone else from making the same mistake in the future. Providers are human beings, and there will always be days when they're tired or distracted. unsafe act ✔✔"an error or a violation committed in the presence of a potential hazard."
slip ✔✔ lapse ✔✔ mistake ✔✔ violation ✔✔ blameworthy event ✔✔includes events that are the result of criminal acts, patient abuse, alcohol or substance abuse on the part of the provider, or acts defined by the organization as being intentionally or deliberately unsafe. A physician attends a luncheon at a restaurant near her work, and consumes several alcoholic beverages. Once at work, she inadvertently drops equipment on the floor several times during a procedure, presenting an infection control risk. She yells at the staff members who remove the contaminated items. Should she be held accountable for her actions? ✔✔Most likely yes: The physician is deliberately impaired, placing the safety of the patient at risk. As you see on the decision tree
What intervention helped prove that catheter-associated bloodstream infections (CLABSIs) were preventable consequences of care? ✔✔A checklist of evidence-based practices applied consistently and collectively every time a catheter is used Reductions in CLABSIs are due to this improvement of the system for placing catheters, not technical innovation or isolated guidelines. Ventilators aren't related to bloodstream infections. The Swiss cheese model of accident causation illustrates what important concept in patient safety? ✔✔Both latent unsafe conditions and active failures (unsafe acts) contribute to harm AND harm results when the layers of defense in a system fail to prevent a hazard from reaching a patient.The Swiss cheese model illustrates how a hazard results in harm by passing through the many "holes" in a safety system, which represent unsafe conditions that lead to unsafe acts and fail to prevent them from causing harm. By understanding the Swiss cheese model of harm, we can see that safety is the result of a system and not just the acts of providers. Why do some patient safety leaders believe the definition of harm should be broader than the definition in the IHI Global Trigger Tool? ✔✔Because health care systems should work to prevent more types of harm than the current definition includes Leaders in the field of patient safety argue that health systems should be more expansive in their definition of harm because the definition affects the scope of improvement work. They believe that health systems can and should prevent more types of harm than the definition includes.
Which of the following is included in the IHI Global Trigger Tool definition of harm? ✔✔Physical injury caused by medical care that triggers additional care Some patient safety leaders want to expand the definition of harm and include the other types of harm listed in this question, including financial harm, psychological harm, and so-called errors of omission, but those are not included in the IHI Global Trigger Tool definition of harm. What is one reason that patient safety has shifted to work on reducing harm in addition to preventing errors? ✔✔Harm is more preventable than providers once thought. Harm is more preventable than providers once thought. A good example is central line-associated bloodstream infections (CLABSIs), a small number of which were once thought to be an inevitable complication of life-saving health care. Providers realized that it was actually possible to almost eliminate central-line infections through improvement efforts including a checklist to ensure all precautions were taken every time. Human error is still a big problem in health care, but reducing error is not the only way to reduce harm. Identifying errors is an important part of improvement, because it allows health care systems to improve unsafe conditions before they cause harm. Patients care about errors, in addition to harm, because errors undermine trust in the health care system.
