NUR 2206 Exam 4
1. medical error
Answer
failure of a planned action to be completed, or the use of wrong plan to achieve an aim
2. situational monitoring
Answer
process of continual scanning your environment
3. STEP is used for
Answer
monitoring situations in the delivery of health care
4. STEP stands from
Answer
status of patient, team members, environment, progress toward goal
5. status of patient includes...
Answer
Pt Hx, VS, Meds, PE, Plan of Care, Psych Issues
6. Team Members includes monitering.............................. Fatigue, Workload, Task Performance,
Skill, Stress
7. environment monitering includes ...
Answer
Facility Info, Admin Info, Human Re- sources, Ability to Triage Acuity. Equipment
8. progress monitering includes..
Answer
What is the status of Team's pts, Do we have established goals for the Team?, What are the
Teams tasks / priority actions, Evaluate - is plan still appropriate?
,9. cross monitoring
Answer
error reduction strategy to provide safety net within the team
10. IM SAFE
Answer
Illness, medication, stress, alcohol and drugs, fatigue, eating and elimination
11. Institute for Safe Medication Practices (ISMP) goals
Answer
advance patient safety worldwide by empowering healthcare community, including consumers,
to prevent medication errors
12. safety policy changes - institutional level
Answer
bar code scanning and safety huddles
13. The Joint Commission (TJC) policy changes
Answer
no abbreviations
14. human error
Answer
predictable, occurs with a lapse in personal behavior, understand how mistakes are made to
prevent & decrease the probability of error
15. human and systems factors
Answer
Refers to the study of human behavior, abilities, limitations, and other characteristics as they
affect the design and smooth operation of equipment, systems, jobs, and work environment
(AHRQ)
16. adverse event (AE)
,any injury caused by medical care that does not rise to level of being sentinel
17. adverse drug event (ADE)
Answer
specific type of AE - any injury resulting form medical intervention related to a drug
18. categories of errors
Answer
adverse event, sentinel event, medication error
19. sentinel event
Answer
An adverse event in which death or serious harm to a patient occurs; usually refers to events
that are not expected or anticipated
20. medication error
Answer
Any preventable event that may cause or lead to unintended
/ incorrect medication use (prescribing, dispensing and administering)
21. how to identify cause of error
Answer
Root cause analysis, and reporting of errors
22. root cause analysis (RCA)
Answer
A structured process for identifying the causal or contributing factors underlying adverse events
or other critical incidents; Identify underlying problems that increase the likelihood of errors
while avoiding focusing on mistakes by individuals
23. reporting of errors
, Blame-free, non-punitive reporting systems
24. unsafe practices
Answer
work arounds, dangerous abbreviations, relying on memory
25. Work-arounds (AHRQ)
Answer
A deviation from the expected pattern of work by by- passing safety features; Often the result of
poorly designed processes or equipment
26. Strategies to Eliminate Errors & Unsafe Practices
Answer
Open communication (TeamStepps), reporting systems, rounding, peer-checking, checklists,
60-second situational awareness, pt ID, safety-enhancing technologies
27. culture of safety key components
Answer
leadership, communication, and the environment
28. environmental safety covers..
Answer
falls, fire, poisoning, suffocation, fire-arms, equipment-related accidents, procedure-related
accidents
29. safety for falls
Answer
use alert bracelet, bed alarms, call bell in reach
30. safety for fire
Answer
RACE
Rescue, Alarm, Contain, Evacuate/extinguish