PSEP - Canada May 2015

This is the pre-test for the PSEP - Canada 'Become a Patient Safety Trainer' Conference in Thunder Bay. Please select the best answer for each question. If you have any issues, please contact Derek Jarvis, PSEP Coordinator, at [email protected].

Which of the following behaviors is particularly valuable to High Reliability Organizations such as health care with high potential for catastrophe?

a) diverse creative thinking

b) being wise after the event

c) regular predictions of disaster

d) refusal to believe disaster can happen

According to the SEIPS (The University of Wisconsin-Madison Systems Engineering Initiative for Patient Safety) model of a health care delivery system, patient safety depends on the interaction of five system components. These are person, tasks, tools, organizational conditions and:

a) health care legislative environment

b) health care physical environment

c) health care business environment

d) health care research environment

A member of your health care team inadvertently administers the wrong dose of medication to a patient. Which of the following responses is most typical of a systems thinking approach to this error?

a) tell the team member to be more aware of hazards

b) send the health care team on a refresher course for correct procedures

c) identify the latent conditions

d) hold the team member personally accountable

James Reason described the Swiss cheese model of organizational defense against adverse events. Core components of defense include

a) processes for identifying the individual who caused the event

b) successive layers of protection and rescue strategies

c) limiting disclosure of errors

d) limiting discussion between physicians and families

Effective health care systems usually have the following property:

a) inter-related components working together towards a common goal

b) separation of component parts to avoid overlap

c) unidirectional information flow from CEO down

d) imperviousness to the external environment

A patient record system is successfully implemented in a health care setting. Five years later an upgrade is installed. Which of the following may be a human factor issue in this situation?

a) staff will have more time to perform other tasks

b) staff may not monitor the system for malfunctions

c) staff may not trust the system to be accurate

d) staff may not understand what the system is reporting

According to the hierarchy of effectiveness, which of the following systems orientated strategies is likely to be most effective in preventing error?

a) tailoring systems to match what people are used to

b) implementing automated systems to help staff memorize, calculate, and monitor

c) integrate design features which forcibly prevent users making errors

d) issue policy and procedural guidelines for particular uses of technology

The Human-Tech Ladder has been successfully used to identify ways in which health care teams interact with technology. Which of the following questions could help people to think about their interaction with a piece of equipment on a physical level?

a) Does the equipment require the user to remember a series of numbers?

b) Is the information provided by the equipment accessible to all relevant team members?

c) Is the equipment too heavy for one person to move easily?

d) Has the technology received a Health Canada license?

Analysis of near misses and adverse events should include answers to:

a) who was at fault?

b) what were the consequences?

c) can we keep the discussion restricted to a few individuals with a need to know?

d) how do we minimize our legal liability?