Culture eats
Process for lunch
Describe culture
Collective mindset norms
Drift
Normalization of deviance
What are the five
... [Show More] elements of an ideal safety culture
Reporting, inform, Just, flexible, learning
James reasons book
Managing the Risk of organizational accidents, 1997
Culture is it driven locally or at the organizational level
Sexton at all believe that culture is more variable among units within the same hospital then among hospitals
What are principles and science of patient safety
1. Standardization and checklists, 2. human factors, 3. teamwork training
How do you raise awareness about patient safety
Through engagement in education such as engaging the team and patient safety initiatives on error reporting near misses and disclosure an apology
How do you respond to patient safety survey results
Identify and disseminate best practices from high-performing units
Concerns for responding to patient safety survey data
Response rate reliability of data
What are surrogates of patient safety culture assessment
Number one, voluntary reporting of near misses, number two must be accompanied by just culture regarding how reports are dealt with in number three patient safety is a strategic priority
3 Principles and science of patient safety
One standardization, checklist, to human factors, three teamwork training
Patient and family involvement and patient safety initiatives may include
Patient advisory Council's, community forums
What are the principles of standardization
Era reduction within departments, across the organization, throughout the industry, and examples include color-coded wristbands
What are the principles of patient safety
1 standardization, 2 checklists, 3 learning from errors, 4 human factors, 5 teamwork training, 5 error reporting and near misses, 7 disclosures
What are the principles of checkless
List of actions that should be performed optimize patient outcomes. They are based on sound theoretical basis and a history of success and patient safety. For example surgical safety checklist, handoff communication.
Patient safety principal learning from errors describe
Here's our opportunities to want to dig deep for a root cause, and look for common causes and determine what we do when we find them
Scribd the principles of human factors
The interrelationship between humans the tools and equipment in the workplace and the environment in which they work. This is different than human error
What are the 6 principles of teamwork training, Or a high-performing team
Team structure, leadership, communication, situation monitoring, mutual support, coordination and collaboration
What is the principal: error reporting and near misses
Staff education, must provide clear expectation of what and how to report and be reviewed routinely and provide the Y such as giving examples storytelling lessons learned
Describe the principle of patient safety disclosure
Identify what needs to be disclosed, understand barriers model disclosure and apology, patient expectations, outline the process steps for the conversation
3 Disclosure barriers
Lack of culture of safety, psychological barriers, legal barriers
What are the process steps for a conversation on patient disclosure
1. designate personnel roles, 2. Conversation outlines, 3. Accommodations for special communication needs, 4. Support services available to the patient family and healthcare team, 5. steps for follow-up conversation, 6. Documentation of the conversation
What are elements that should be included in the conversation Outline for disclosure
What happened, convenience of regret, steps already taken to prevent reoccurrence, change in patient's care plan for outlook, who will contact the family next, support services to patient and family members
Describe affective versus ineffective disclosures
Effective disclosures provide the family with all information needed for appropriate care decisions and cannot be measured solely on the basis of whether malpractice litigation was avoided, and ineffective disclosure does not serve the patient because important information is not communicated
Lack of healthcare literacy leads to
Readmissions, inability to navigate the healthcare spectrum, increase health costs, limited preventative medicine, self-reported poor health
What are four balance measures for managing change
Patient safety implications, proactive identification, countermeasures, post change monitoring
What is psychological safety
Psychological safety is a believe that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes
Psychological safety requires
Softening of authority gradients
Psychological safety is critical to
A learning environment that enables individuals to willingly contribute to collective work on a team
Traditional punitive healthcare cultures impede the creation of psychological safety by
Blaming people for hours
Human error quote
"The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes." Dr. Lucian Leape Professor Harvard school of public health testimony before Congress on healthcare quality improvement
Institute of medicine book on building a safe healthcare system
"To Err is human" , With a principal first, do no harm
What are three elements about human error described in to air is human
1. Human error cannot be one eradicated because it is a part of human condition, 2. The consequences of errors can be mitigated, 3. we can reduce the risk that can lead to harm
Describe accountability of errors the two categories
At risk behavior and reckless behavior
Describe at risk behavior and how to manage
Manage at risk behaviors requires feedback, coaching
Describe how to manage reckless behavior
Reckless behavior requires administrative consequence
What are some challenges with accountability for behavior
Demanding perfection versus, "no harm,No foul. Associates cannot be expected to work without errors yet they must be held accountable for the decisions with the same consequences regardless of outcome
Is it good example of a culture of accountability model
Just culture [Show Less]