Podcast
Questions and Answers
What are the six building blocks of a health system?
What are the six building blocks of a health system?
What is the primary goal of a well-functioning health system?
What is the primary goal of a well-functioning health system?
What is one way that a well-functioning health system responds to a population's needs and expectations?
What is one way that a well-functioning health system responds to a population's needs and expectations?
What is one of the benefits of a well-functioning health system?
What is one of the benefits of a well-functioning health system?
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What do the six building blocks of a health system aim to achieve?
What do the six building blocks of a health system aim to achieve?
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What is the purpose of the World Health Organization's handbook on monitoring the building blocks of health systems?
What is the purpose of the World Health Organization's handbook on monitoring the building blocks of health systems?
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What is the primary expectation of healthcare systems by society?
What is the primary expectation of healthcare systems by society?
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What is the main limitation of traditional healthcare responses to errors?
What is the main limitation of traditional healthcare responses to errors?
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According to the Swiss Cheese Model, what causes most accidents?
According to the Swiss Cheese Model, what causes most accidents?
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What is the primary reason why aviation and nuclear power are good industries to learn from when improving safety in healthcare?
What is the primary reason why aviation and nuclear power are good industries to learn from when improving safety in healthcare?
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What is the main goal of a systems approach to healthcare?
What is the main goal of a systems approach to healthcare?
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What is the term for accidents that occur due to the complexity of systems?
What is the term for accidents that occur due to the complexity of systems?
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Where do active errors typically occur?
Where do active errors typically occur?
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What is the characteristic of systems that makes it difficult to anticipate the effects of change?
What is the characteristic of systems that makes it difficult to anticipate the effects of change?
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Why are systems failures often unexpected or unanticipated?
Why are systems failures often unexpected or unanticipated?
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What is the main limitation of expecting perfection from healthcare professionals?
What is the main limitation of expecting perfection from healthcare professionals?
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What was the patient originally being treated for when the adverse event occurred?
What was the patient originally being treated for when the adverse event occurred?
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What was the medication error that occurred in the Automated Dispensing Cabinet (ADC)?
What was the medication error that occurred in the Automated Dispensing Cabinet (ADC)?
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What was the outcome of the adverse event?
What was the outcome of the adverse event?
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What was the reason the nurse did not realize the mistake?
What was the reason the nurse did not realize the mistake?
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What was the issue with the scanning process in the pharmacy?
What was the issue with the scanning process in the pharmacy?
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What was the prescriber's order after the adverse event was discovered?
What was the prescriber's order after the adverse event was discovered?
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What was the reason the patient did not receive aggressive measures?
What was the reason the patient did not receive aggressive measures?
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What was the similarity between the midazolam and magnesium sulfate bags?
What was the similarity between the midazolam and magnesium sulfate bags?
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What was the issue with the pharmacy's controlled substance safe?
What was the issue with the pharmacy's controlled substance safe?
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What type of error was the similar labeling of the bags?
What type of error was the similar labeling of the bags?
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What is a characteristic of high-reliability organizations?
What is a characteristic of high-reliability organizations?
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What is a key feature of high-pressure environments in high-reliability organizations?
What is a key feature of high-pressure environments in high-reliability organizations?
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What is the focus of high-reliability organizations in terms of error response?
What is the focus of high-reliability organizations in terms of error response?
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What is the term for 'errors waiting to happen' in the Swiss Cheese Model?
What is the term for 'errors waiting to happen' in the Swiss Cheese Model?
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What is a key benefit of high-reliability organizations in terms of safety?
What is a key benefit of high-reliability organizations in terms of safety?
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What is the term for being aware of one's surroundings in a high-reliability organization?
What is the term for being aware of one's surroundings in a high-reliability organization?
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What is an example of a latent error in the pharmacy?
What is an example of a latent error in the pharmacy?
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What is an example of an active error in the pharmacy?
What is an example of an active error in the pharmacy?
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According to the Swiss Cheese Model, what is a barrier that can prevent an adverse event?
According to the Swiss Cheese Model, what is a barrier that can prevent an adverse event?
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What is the primary goal of the Donabedian Model?
What is the primary goal of the Donabedian Model?
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What is an example of a hospital-acquired infection quality measure?
What is an example of a hospital-acquired infection quality measure?
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What is the reason for the emergency landing of the Boeing 737-900?
What is the reason for the emergency landing of the Boeing 737-900?
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What is the purpose of checklists in healthcare?
What is the purpose of checklists in healthcare?
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What is the consequence of a proxy scan in the context of infusion bags?
What is the consequence of a proxy scan in the context of infusion bags?
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Why did the nurse have difficulty reading the labels of the infusion bags in the patient's room?
Why did the nurse have difficulty reading the labels of the infusion bags in the patient's room?
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What is the purpose of the Agency for Healthcare Research and Quality (AHRQ)?
What is the purpose of the Agency for Healthcare Research and Quality (AHRQ)?
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Study Notes
Latent Errors and Active Failures
- A physician prescribed 2g of intravenous magnesium sulfate to a patient in palliative care, but a night nurse mistakenly administered midazolam 100mg instead, leading to respiratory depression and ultimately, the patient's death.
- The error occurred due to a pharmacy error when refilling the automated dispensing cabinet (ADC), which was not caught by the nurse or pharmacist.
Health Systems
- A health system consists of six building blocks:
- Service delivery
- Health workforce
- Health information systems
- Access to essential medicines
- Financing
- Leadership/governance
- A well-functioning health system responds to a population's needs and expectations by:
- Improving health status
- Defending against threats to health
- Protecting against financial consequences of ill-health
- Providing equitable access to patient-centered care
High-Reliability Organizations
- High-reliability organizations operate in complex, high-risk environments without serious accidents or catastrophic failures.
- Characteristics of high-reliability organizations include:
- Preoccupation with failure
- Reluctance to simplify
- Sensitivity to operations
- Deference to expertise
- Commitment to resilience
- Examples of high-reliability organizations include military aircraft carriers and the aviation industry.
Errors and System Failures
- Active errors occur at the "sharp end" of the system, involving frontline personnel, and are often visible and immediate.
- Latent errors ("blunt end") are accidents waiting to happen, not in direct contact with patients, and are often organizational and/or design failures.
- System failures can occur due to tight coupling, interdependence, and time sensitivities.
- A systems approach focuses on catching human error before it occurs or stopping it before harm is done to the patient.
Examples of Errors and System Failures
- Similar bag labels inside the overwrap can contribute to look-alike errors.
- Unaccounted for midazolam discrepancy can lead to errors in medication administration.
- Scanning process flaws can lead to errors in documentation.
- Stocking errors can occur due to misplacement of medications in the ADC.
- Selection of the wrong infusion can occur due to failure to notice differences between medications.
- Difficulty scanning the barcode can lead to workarounds and errors.
- Proxy scan can lead to inaccurate documentation.
- Low lighting can contribute to errors in reading labels.
Swiss Cheese Model and Near Misses
- The Swiss Cheese Model recognizes that systems-based errors are most often the cause of patient safety problems.
- Near misses are opportunities to improve safety and prevent future errors.
Donabedian Model and Quality Measures
- The Donabedian Model is a well-established model to evaluate systems and health care quality and safety.
- Quality measures include:
- Structure (e.g., hospital-acquired infections, staffing)
- Process (e.g., communication, double checks)
- Outcomes (e.g., readmission rates, medication errors)
Systems Approach to Health Care
- Catastrophic failures are rarely caused by isolated errors committed by individuals.
- A systems approach focuses on catching human error before it occurs or stopping it before harm is done to the patient.
- Expecting perfection from humans working in complex, high-stress environments is unrealistic.
- A systems approach is necessary to improve safety in health care.
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Description
Test your knowledge on the fundamental components of a health system, as defined by the World Health Organization. Learn about the six building blocks of health systems, including service delivery, health workforce, and more. Assess your understanding of what makes a well-functioning health system.
