PS 103

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lesson 1

x

Human factors is the study of:

All of the above Human factors is an established science that uses many disciplines to understand how people perform under different circumstances. This engineering discipline deals with the interface of people, equipment, and the environment.

Which of the following is an example of unconscious processing by the brain?

A and C Optical illusions and mistakes involving look-alike drugs and names reflect unconscious processing by the human brain. Unconscious processing is a fundamental part of human cognition that can lead to human error even when people are trying their best. Safe systems take these known characteristics of human cognition into account to help people do things the right way.

When attempting to decrease the risk of error, it’s important to use human factors principles because:

If you understand the factors that affect human performance on critical tasks, you can design a safer system.

You visit the local convenience store looking for a refreshing drink on a pleasant day. You know that you want a new type of cola beverage you’ve heard advertised on the radio, and reach into the refrigerator for what you think is the caffeine-free version of that cola. After you pay, pop the can, and begin drinking, you find that you purchased the sugar-free version instead (whoops!). What most likely contributed to this error?

Look-alike cans/labels

At the end of a double shift, an experienced nurse with an excellent track record gives a medication to the wrong patient. Based on human factors principles, what would you guess was the biggest contributor to this error?

The nurse was prone to error because she was tired.

Human factors is the study of:

All the factors that make it easier to do work in the right way

You visit the local convenience store looking for a refreshing drink on a pleasant day. You know that you want a new type of cola beverage you’ve heard advertised on the radio, and reach into the refrigerator for what you think is the caffeine-free version of that cola. After you pay, pop the can, and begin drinking, you find that you purchased the sugar-free version instead (whoops!). What most likely contributed to this error?

Look-alike cans/labels

Which of the following factors can increase human risk for error?

All of the above The best answer is all of the above. All three choices include factors that impact human performance and can increase risk for error.

At the end of a double shift, an experienced nurse with an excellent track record gives a medication to the wrong patient. Based on human factors principles, what would you recommend as the best way to prevent the same error from recurring?

Improving medication administration processes

When attempting to decrease the risk of error, it’s important to use human factors principles because:

If you understand the factors that affect human performance on critical tasks, you can design a safer system.

Lesson 2

x

Which of the following is a basic strategy for minimizing the opportunity for error in a process?

Standardizing how the process is completed

Which of the following statements about redundancies within processes is always true?

None of the above None of these statements is always true. In high-risk situations — such as the medication administration process — you may need redundancy to ensure safety. Although a typical redundancy involves one person checking the work of another, you can also use technology to "double check." It’s important to keep in mind that it is possible for two people to make the same mistake and double checks can still allow the opportunity for error.

Which of the following likely needs to be improved about the new process to review vital signs?

It needs to be simplified.

At the end of your training session on the new EHR, you are handed a two-sided laminated card titled "Quick Start Guide." It provides step-by-step instructions for basic tasks such as entering orders and writing daily notes in the EHR. This is an example of:

Avoiding reliance on memory

The first time you admit a patient to the hospital using the new EHR, you see a screen pop up as you are attempting to enter orders. At the top it says, "You must enter orders for DVT (blood clot) prevention before completion of this admission order set. Click here to complete this order." This pop-up box is an example of the use of:

A forcing function

Which of the following is a basic strategy for minimizing the opportunity for error in a process?

Reducing the number of steps

Which of the following is an important reason for checklists in health care?

Checklists prompt providers to remember and appreciate the importance of tasks.

Which of the following likely needs to be improved about the new process to review vital signs?

.It needs to be simplified.

The first time you admit a patient to the hospital using the new EHR, you see a screen pop up as you are attempting to enter orders. At the top it says, "You must enter orders for DVT [blood clot] prevention before completion of this admission order set. Click here to complete this order." This pop-up box is an example of the use of:

A and B The best answer is A and B. The pop-up screen is a forcing function because it makes it impossible to skip a task; this is a standardizing mechanism that reduces variation in this ordering process. This is not an example of simplification because it actually adds another step.

At the end of your training session on the new EHR, you are handed a two-sided laminated card titled "Quick Start Guide." It provides step-by-step instructions for basic tasks such as entering orders and writing daily notes in the EHR. This is an example of:

Avoiding reliance on memory

lesson 3

x

Which of the following concepts does this scenario demonstrate?

All of the above All of the above is the best answer. In this case, the computer has information, but not all of the information. The system does not seem to allow for the fact that there will sometimes be additional information that caregivers must take into account. Instead, it tries to force caregivers to follow rigid rules. Remember: Human beings must still be very present when interacting with technology to ensure its proper and effective use.

Which of the following statements about computerized prescriber order entry systems (CPOEs) is true?

Several studies have disputed the claim that they reduce errors.

Which of the following is the best example of using technology to improve safety and prevent errors?

Giving nursing assistants electronic tablets to ensure there’s no delay in recording patients’ vital signs

Effective ways for addressing defects in the human-technology interface include:

Testing the technology in real-world situations

You’re caring for a patient with diabetes who was admitted to your hospital with an elevated blood glucose level. She is on an insulin pump that is programmed to deliver one unit of insulin per hour through her intravenous (IV) line. How does this technology help make her care safer?

The pump helps automate a complex care process.

Which of the following statements about bar-cording systems is true?

They can help providers keeps track of laboratory specimens, identify medications and medical equipment, and identify patients.

Effective ways for addressing defects in the human-technology interface include:

A and B When developing or trying out a new technology, it’s essential to test the technology in the environment in which it will be used. It’s also essential to involve those who will use the technology in its design. In the absence of these steps, it’s possible that serious design problems will surface later — in a way that could hurt patients. Attending to cost will not improve the interface between technology and the humans who will use it.

What does this block best exemplify?

How technology that dictates your work — rather than facilitates it — can introduce unintended problems

You’re caring for a patient with diabetes who was admitted to your hospital with an elevated blood glucose level. She is on an insulin pump that is programmed to deliver one unit of insulin per hour through her intravenous (IV) line. Which of the following is a risk of this technology?

The pump could malfunction.

Which of the following is the best example of using technology to improve safety and prevent errors?

Giving nursing assistants electronic tablets to ensure there’s no delay in recording patients’ vital signs

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