Question 1

What are the current patient safety characteristics of your organizational culture? Identify at least three aspects of your culture that need to be changed with regard to patient safety, and suggest strategies for change.

Accepted Answer

The current patient safety characteristics of our organizational culture include a strong emphasis on following established protocols and procedures, a commitment to continuous improvement through regular training and education, and a culture of open communication and transparency when it comes to reporting errors or near-misses.

However, there are three aspects of our culture that need to be changed with regard to patient safety. Firstly, there is a need to improve the culture of blame and shame around medical errors. Instead of focusing on assigning blame, we need to shift towards a culture of learning from mistakes and implementing systems to prevent similar errors in the future. This can be achieved by implementing a "just culture" approach, where individuals are held accountable for their actions, but the focus is on system improvement rather than punishment.

Secondly, there is a need to address issues of hierarchy and power differentials within the healthcare team. In order to improve patient safety, all team members need to feel empowered to speak up and voice their concerns without fear of retribution. Strategies for change could include implementing team training programs that emphasize the importance of open communication and mutual respect, as well as creating a culture where all team members are encouraged to contribute to decision-making processes.

Lastly, there is a need to improve the culture of patient and family engagement in the care process. Patients and their families are valuable partners in ensuring their own safety, and their input can provide valuable insights into potential risks or areas for improvement. Strategies for change could include implementing patient and family advisory councils, providing education and resources to empower patients to be active participants in their care, and creating systems for soliciting and acting on patient feedback.

Overall, these changes will require a concerted effort to shift the mindset and behaviors of all individuals within the organization. This will involve ongoing education and training, clear communication of expectations, and a commitment to modeling and reinforcing the desired behaviors. It will also require a willingness to adapt and evolve as we learn from our experiences and strive to continuously improve our patient safety culture.

Question 2

Describe a current technology that you use in patient care that would benefit from human factors engineering concepts. What are some ways this technology should be improved?

Accepted Answer

One current technology that could benefit from human factors engineering concepts in patient care is the electronic health record (EHR) system. EHRs are used by healthcare providers to document patient information, track medical history, and manage treatment plans. However, these systems can be complex and difficult to navigate, leading to potential errors and inefficiencies in patient care.

One way to improve EHR systems using human factors engineering concepts is to focus on user interface design. This includes making the system more intuitive and user-friendly, with clear navigation and organization of information. Additionally, incorporating features such as customizable templates and shortcuts can help streamline the documentation process and reduce the cognitive load on healthcare providers.

Another improvement would be to optimize the integration of EHR systems with other healthcare technologies, such as medical devices and telemedicine platforms. This would involve ensuring seamless interoperability and data exchange, as well as minimizing disruptions to workflow.

Furthermore, incorporating user feedback and conducting usability testing can help identify and address any usability issues or pain points in the EHR system. This iterative approach to design and development can lead to continuous improvement and a more user-centered EHR system.

Overall, applying human factors engineering concepts to EHR systems can lead to improved usability, efficiency, and safety in patient care. By prioritizing the needs and experiences of healthcare providers, EHR technology can better support their clinical workflows and ultimately enhance the quality of patient care.

Question 3

Identify a workaround that you have used and analyze why you chose this risk-taking behavior over behavior that conforms to a safety culture.

Accepted Answer

One workaround that I have used in the past is bypassing certain safety protocols in order to meet a tight deadline. For example, I have skipped certain steps in a safety checklist in order to complete a project on time. I chose this risk-taking behavior over conforming to a safety culture because I felt pressure to meet the deadline and deliver results. In the moment, I prioritized the immediate need to finish the project over the potential long-term consequences of compromising safety. Additionally, I may have felt that the safety protocols were overly cautious and that I could complete the task without following every step. However, looking back, I realize that this was a risky decision and could have resulted in serious consequences. In the future, I will prioritize safety over deadlines and seek alternative solutions to meet project requirements without compromising on safety.

Question 4

The GAO (2016) interviewed patient safety experts and the related literature to identify three key gaps in patient safety practice implementation:
a lack of (1) information about the effect of contextual factors on implementation of patient safety practices, (2) sufficiently detailed information on the experience of hospitals that have previously used specific patient safety implementation strategies, and (3) valid and accurate measurement of how frequently certain adverse events occur. (p. 22)
Select one of these gaps and describe in detail how nursing informatics could help close this gap.

Accepted Answer

The answer of The GAO (2016) interviewed patient safety experts...

Question 5

Although nurses have an ethical duty to ensure patient safety, increasing demands on professionals in complex and fast-paced healthcare environments may lead to workarounds. What is a workaround?
A) A practice that deviates from accepted and expected practice protocols
B) A shortcut to save time
C) An inappropriate action or omission of appropriate actions
D) All of these are correct.

Accepted Answer

A workaround is a practice that deviates from accepted protocols, often used as a shortcut to save time, and can involve inappropriate actions or omissions.

Question 6

A safety culture is a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment. Conversely, a just culture emphasizes individual accountability and:
A) encourages workarounds in the interest of saving time as long as no harm occurs.
B) encourages error reporting and seeks to understand workflow and process issues that lead to errors.
C) allows reckless behavior if it is justified.
D) All of these are correct.

Accepted Answer

A just culture encourages error reporting and seeks to understand workflow and process issues that lead to errors, while still holding individuals accountable for their actions.

Question 7

Multiple false alarms may lead to alarm fatigue and compromise patient safety by slow response or no response to physiologic alarms. Strategies to improve alarm response include:
A) increasing the sensitivity of the physiologic monitors and feeding alarms directly to beepers or phones carried by professionals.
B) feeding alarm data into a reporting database for further analysis.
C) discouraging healthcare professionals from rounding with physicians because they are often guilty of ignoring alarms.
D) All of these are correct.

Accepted Answer

Feeding alarm data into a reporting database for further analysis can help identify patterns and improve alarm management, reducing alarm fatigue. Increasing sensitivity or discouraging rounding are not effective strategies.

Question 8

Integrating technology into the medication administration cycle helps to reduce errors by:
A) performing electronic checks against a database of safe medication administration parameters and providing alerts.
B) reducing the workload and increasing the efficiency of clinicians.
C) Employing human factors engineering principles to streamline workflow processes.
D) All of these are correct.

Accepted Answer

The answer of Integrating technology into the medication administration cycle...

Question 9

Smart pumps are designed for safe administration of high-hazard drugs and to reduce adverse drug events during intravenous medication administration. What happens when a hard alarm is generated by a smart pump?
A) A licensed clinician or a pharmacist can override a hard alarm and administer the drug as programmed.
B) The pump must be reprogrammed so that the rate and dose for administration of the high-hazard intravenous drug falls within the facility's safe infusion parameters.
C) The nurse must call the physician for a verbal order to turn off the smart pump technology and administer the drug as ordered.
D) Members of the biomedical engineering department can reprogram the pump to avoid these nuisance alarms.

Accepted Answer

A hard alarm on a smart pump indicates that the programmed infusion parameters are outside the facility's safety limits, and the pump must be reprogrammed to ensure safe administration within those limits.

Question 10

Radio frequency identifier (RFID) technology may gradually replace bar-code technology in the medication administration cycle because RFID provides:
A) opportunities to check patient identification before administration of the medication.
B) easy integration into the electronic health record.
C) reduced potential that a counterfeit medication is inadvertently introduced into the supply.
D) All of these are correct.

Accepted Answer

The answer of Radio frequency identifier (RFID) technology may gradually...

Question 11

In addition to organizational commitment of resources to address safety concerns, what is a key feature of a safety culture as identified by the Agency for Healthcare Research and Quality?
A) Acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations
B) A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
C) Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
D) All of these are correct.

Accepted Answer

A safety culture includes acknowledgment of high-risk activities, a blame-free environment, and collaboration across ranks and disciplines.

Question 12

Nurses have an ethical duty to ensure patient safety.

Accepted Answer

Nurses have a professional and ethical obligation to prioritize and ensure the safety and well-being of their patients as part of their duty of care.

Question 13

In a "just culture," system or process issues that lead to unsafe behaviors and errors are addressed by changing practices or workflow processes, and a clear message is communicated that reckless behaviors will not be tolerated.

Accepted Answer

A "just culture" focuses on identifying and correcting systemic issues while holding individuals accountable for reckless behavior, promoting safety and fairness.

Question 14

When someone disregards established policies and procedures, it is thought of as reckless behavior.

Accepted Answer

Reckless behavior involves acting without regard for the consequences, which includes ignoring established policies and procedures.

Question 15

Organizations themselves can engage in root-cause analysis or failure modes and effects analysis to examine medical errors closely and to determine the system processes that need to be changed to prevent similar future errors.

Accepted Answer

Organizations can use root-cause analysis and failure modes and effects analysis to identify and address system processes that contribute to medical errors, aiming to prevent future occurrences.

Question 16

Many organizations are looking to informatics technology to help manage complex safety issues by using smart technologies that provide knowledge access to users, provide automated safety checks, and improve communication processes.

Accepted Answer

Organizations are increasingly leveraging informatics technology to enhance safety management by utilizing smart technologies for better knowledge access, automated safety checks, and improved communication.

Question 17

The top patient safety issues are identified as early discharge and polypharmacy.

Accepted Answer

The answer of The top patient safety issues are identified...

Question 18

Once the technology is integrated into the organization, biomedical engineers can become valuable partners in promoting patient safety through appropriate use of these technologies.

Accepted Answer

Biomedical engineers play a crucial role in ensuring that medical technologies are used safely and effectively, thereby enhancing patient safety.

Question 19

The Patient Safety and Quality Improvement Act of 2005 mandated the creation of a national database of medical errors and funded several organizations to analyze these data with the goal of developing shared learning to prevent medical errors.

Accepted Answer

The Patient Safety and Quality Improvement Act of 2005 established a framework for the creation of Patient Safety Organizations (PSOs) to collect and analyze data on medical errors, aiming to improve patient safety and healthcare quality.

Question 20

Organizational leaders must drive the culture change by making a visible commitment to safety and by enabling staff to share safety information openly. Some of the strategies suggested by the Institute for Healthcare Improvement include appointing a safety champion for every unit, creating an adverse event response team, and reenacting or simulating adverse events to better understand the organizational or procedural processes that failed.

Accepted Answer

Organizational leaders play a crucial role in driving culture change by visibly committing to safety and fostering an environment where staff can openly share safety information. Strategies like appointing safety champions and simulating adverse events help in understanding and improving safety processes.

Quiz 15: Informatics Tools to Promote Patient Safety and Quality Outcomes

What are the current patient safety characteristics of your organizational culture? Identify at least three aspects of your culture that need to be changed with regard to patient safety, and suggest strategies for change.

Describe a current technology that you use in patient care that would benefit from human factors engineering concepts. What are some ways this technology should be improved?

Identify a workaround that you have used and analyze why you chose this risk-taking behavior over behavior that conforms to a safety culture.

Although nurses have an ethical duty to ensure patient safety, increasing demands on professionals in complex and fast-paced healthcare environments may lead to workarounds. What is a workaround?

A safety culture is a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment. Conversely, a just culture emphasizes individual accountability and:

Multiple false alarms may lead to alarm fatigue and compromise patient safety by slow response or no response to physiologic alarms. Strategies to improve alarm response include:

Integrating technology into the medication administration cycle helps to reduce errors by:

Smart pumps are designed for safe administration of high-hazard drugs and to reduce adverse drug events during intravenous medication administration. What happens when a hard alarm is generated by a smart pump?

Radio frequency identifier (RFID) technology may gradually replace bar-code technology in the medication administration cycle because RFID provides:

In addition to organizational commitment of resources to address safety concerns, what is a key feature of a safety culture as identified by the Agency for Healthcare Research and Quality?