PS 102 Questions and Answers 100% Pass

PS 102 Questions and Answers 100% Pass Swiss cheese model of accident causation ✔Ans✔ Serious adverse events are almost always the result of multiple failed opportunities to stop a hazard from causing harm Latent co ...

PS 102 Questions and Answers 100% Pass Swiss cheese model of accident causation ✔Ans✔ Serious adverse events are almost always the result of multiple failed opportunities to stop a hazard from causing harm Latent conditions ✔Ans✔ 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 ✔Ans✔ 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? ✔Ans✔ 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 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? ✔Ans✔ 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.1 Which of the following factors makes health care dangerous to patients and providers? ✔Ans✔ 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." "Latent errors" are best defined as: ✔Ans✔ Defects in the design and organization of processes and systems. -Latent errors are defects in the design or organization of processes and systems. These insidious errors can go unnoticed or ignored, but in time are likely to result in patient harm — or, a so-called "active error" in care. For example, operating on the wrong surgical site is an active error with immediate effects; however, any number of latent errors in surgical processes can contribute to a wrong-site surgery. Nearing the end of her 18-hour work shift, a resident sees a patient 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. Which of the following is a latent unsafe condition in the system that contributes to the resident's error? ✔Ans✔ The best answer is the resident's long work schedule. Latent conditions are flaws in the design of systems that create opportunities for error. Two women — one named Camilla Tyler, the other named Camilla Taylor — arrive at a particularly busy emergency department at about the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an antibiotic. The doctor orders the medications, but mixes up the patients when filling out the order sheets. The pharmacist dispenses the medications as ordered, and the nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor. What is the active error in this scenario? ✔Ans✔ 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? ✔Ans✔ 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 ✔Ans✔ "an error or a violation committed in the presence of a potential hazard."1