IHI PI: 101

The term "normalized deviance" refers to:

Acceptance of events that are initially allowed because no catastrophic harm appears to result.

A medical unit in a hospital is in the midst of hiring some new physicians. During an orientation for new employees, a senior leader stands up and says, "We expect that the same rules apply to everyone on the unit, regardless of position." Which aspect of a culture of safety does this unit seem to value?

Accountability

According to WHO, in developed countries worldwide, what is the approximate likelihood that a hospitalized patient will be harmed while receiving care? A <1% B 10% C 50% D >75%

B 10%

James is a first-year surgery resident on his first pediatric rotation. His attending (consultant) asks him to start intravenous (IV) replacement fluids on a two-year-old boy who is having vomiting and diarrhea. Having trouble remembering the guidelines for calculating fluid replacement rates for very small children, James asks Maria, a nurse on the unit. Maria responds, "You're the doctor. It's your job to decide this." James picks a rate that is much too high, putting the child into fluid overload. To prevent this type of error from recurring in this unit, which of the following is MOST important? (A) Clear medical guidelines for fluid replacement in patients of all ages (B) An improved culture of safety and teamwork (C) Closer supervision of residents, especially in the first year (D) More severe, well-publicized consequences for providers who are reckless

B an improved culture of teamwork and safety

Safety has been called a "dynamic non-event" because when humans are in a potentially hazardous environment: (A) It is natural to establish and follow safe practices (B) It requires the same kind of thinking that causes problems to set them right (C) It takes significant work to ensure nothing bad happens (D) There is generally a high prevalence of "near misses"

C it take significant work to ensure nothing bad happens

Since the publication of To Err Is Human in 1999, the health care industry overall has seen which of the following improvements? (A) A 75 percent reduction in preventable medical errors (B) Stronger repercussions for providers who commit preventable medical errors (C) Wider awareness that preventable errors are a problem (D) Wider recognition that medical errors are most often attributable to individual performance (E) All of the above

C wider awareness that preventable errors are a problem

James is a first-year surgery resident on his first pediatric rotation. His attending (consultant) asks him to start intravenous (IV) replacement fluids on a two-year-old boy who is having vomiting and diarrhea. Having trouble remembering the guidelines for calculating fluid replacement rates for very small children, James asks Maria, a nurse on the unit. Maria responds, "You're the doctor. It's your job to decide this." James picks a rate that is much too high, putting the child into fluid overload. Who is likely to be negatively affected by this medical error? (A) The patient and his family (B) James (the first-year surgery resident) (C) Maria (the nurse on the unit) (D) All of the above

D all of the above

One hospital CEO insists on including performance data in the hospital's annual report. "We do very well on most measures, except for one or two, but we put those in anyway," she says. "We want to hold ourselves accountable." Does this practice demonstrate effective or ineffective leadership?

Effective leadership: Being transparent, even about poor results, is a mark of a good leader.

Which of these is a behavior providers should adopt to improve patient safety?

Follow written safety protocols, even if they slow you down.

Which of the following should you keep in mind as your hospital redesigns the way it handles knee replacements?

How system components are integrated with one another is as important as how well they function independently.

At the large multi-specialty clinic in which you work, there have been two near misses and one medical error because various clinicians did not follow up on patient results. Different caregivers were involved each time. When asked why they failed to follow up, each caregiver said he or she forgot. A nurse who realized that his colleagues weren't consistently following up on patient results reported the problem to the clinic leadership right away. Which response would be most consistent with a culture of safety?

Investigating the problem and seeking systems solutions

You meet with the nurse administrator responsible for improvement when issues in the process of care are identified by those on the wards. She listens carefully to your concern, but in the end says she can only try to help improve nursing issues, and not those that extend to pharmacy or transport. The primary reason your meeting is unlikely to lead to an adequate solution is:

The nurse administrator did not have the appropriate span of responsibility to engage the system components needed to solve the problem.

Which of the following is typically true of "weak signals"?

They can combine with other human or environmental factors to result in catastrophe.

At the large multi-specialty clinic in which you work, there have been two near misses and one medical error because various clinicians did not follow up on patient results. Different caregivers were involved each time. When asked why they failed to follow up, each caregiver said he or she forgot. Based on what you know, how would you classify the caregivers' behavior?

human error