Health Systems and Building Blocks
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What are the six building blocks of a health system?

  • Health education, health workforce, health financing, service delivery, access to medicines, and leadership
  • Service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance (correct)
  • Service delivery, health workforce, health financing, access to medicines, leadership, and health education
  • Health information systems, health workforce, health education, access to medicines, financing, and leadership

    • What is the primary goal of a well-functioning health system?

  • To reduce the financial costs of healthcare
  • To improve the health status of individuals, families, and communities (correct)
  • To provide equitable access to patient-centered care
  • To defend the population against what threatens its health

    • What is one way that a well-functioning health system responds to a population's needs and expectations?

  • By reducing access to healthcare for vulnerable populations
  • By improving the health status of individuals, families, and communities (correct)
  • By providing access to healthcare only to those who can afford it
  • By increasing the cost of healthcare

    • What is one of the benefits of a well-functioning health system?

    <p>It protects people against the financial consequences of ill-health</p> Signup and view all the answers

    What do the six building blocks of a health system aim to achieve?

    <p>To respond to a population's needs and expectations in a balanced way</p> Signup and view all the answers

    What is the purpose of the World Health Organization's handbook on monitoring the building blocks of health systems?

    <p>To provide a framework for measuring health system indicators and their strategies</p> Signup and view all the answers

    What is the primary expectation of healthcare systems by society?

    <p>To provide effective and safe care</p> Signup and view all the answers

    What is the main limitation of traditional healthcare responses to errors?

    <p>They focus too much on individual errors</p> Signup and view all the answers

    According to the Swiss Cheese Model, what causes most accidents?

    <p>Many small errors throughout the system</p> Signup and view all the answers

    What is the primary reason why aviation and nuclear power are good industries to learn from when improving safety in healthcare?

    <p>They have a history of catastrophic failures that can inform healthcare</p> Signup and view all the answers

    What is the main goal of a systems approach to healthcare?

    <p>To catch human error before it occurs or to stop it before harm is done</p> Signup and view all the answers

    What is the term for accidents that occur due to the complexity of systems?

    <p>Normal accidents</p> Signup and view all the answers

    Where do active errors typically occur?

    <p>At the point of contact between a human and the larger system</p> Signup and view all the answers

    What is the characteristic of systems that makes it difficult to anticipate the effects of change?

    <p>If one part of the system changes, other parts also change</p> Signup and view all the answers

    Why are systems failures often unexpected or unanticipated?

    <p>Because of the complexity of systems</p> Signup and view all the answers

    What is the main limitation of expecting perfection from healthcare professionals?

    <p>It is unrealistic</p> Signup and view all the answers

    What was the patient originally being treated for when the adverse event occurred?

    <p>Hypomagnesemia</p> Signup and view all the answers

    What was the medication error that occurred in the Automated Dispensing Cabinet (ADC)?

    <p>A midazolam bag was stocked in the wrong bin</p> Signup and view all the answers

    What was the outcome of the adverse event?

    <p>The patient experienced respiratory depression and later died</p> Signup and view all the answers

    What was the reason the nurse did not realize the mistake?

    <p>The labels on the bags looked similar</p> Signup and view all the answers

    What was the issue with the scanning process in the pharmacy?

    <p>The scanning process only prompted scanning of the first barcode</p> Signup and view all the answers

    What was the prescriber's order after the adverse event was discovered?

    <p>Administer flumazenil</p> Signup and view all the answers

    What was the reason the patient did not receive aggressive measures?

    <p>The patient had a DNR order</p> Signup and view all the answers

    What was the similarity between the midazolam and magnesium sulfate bags?

    <p>All of the above</p> Signup and view all the answers

    What was the issue with the pharmacy's controlled substance safe?

    <p>A pharmacist reported a midazolam bag discrepancy</p> Signup and view all the answers

    What type of error was the similar labeling of the bags?

    <p>Latent error</p> Signup and view all the answers

    What is a characteristic of high-reliability organizations?

    <p>Preoccupation with failure</p> Signup and view all the answers

    What is a key feature of high-pressure environments in high-reliability organizations?

    <p>Constantly changing conditions</p> Signup and view all the answers

    What is the focus of high-reliability organizations in terms of error response?

    <p>Focusing on underlying systems</p> Signup and view all the answers

    What is the term for 'errors waiting to happen' in the Swiss Cheese Model?

    <p>Latent errors</p> Signup and view all the answers

    What is a key benefit of high-reliability organizations in terms of safety?

    <p>They rarely experience safety problems</p> Signup and view all the answers

    What is the term for being aware of one's surroundings in a high-reliability organization?

    <p>Situational awareness</p> Signup and view all the answers

    What is an example of a latent error in the pharmacy?

    <p>Chronic difficulty scanning infusion bag barcodes</p> Signup and view all the answers

    What is an example of an active error in the pharmacy?

    <p>A pharmacy technician misplacing the midazolam bag in the magnesium bin</p> Signup and view all the answers

    According to the Swiss Cheese Model, what is a barrier that can prevent an adverse event?

    <p>Double check</p> Signup and view all the answers

    What is the primary goal of the Donabedian Model?

    <p>To evaluate the quality of healthcare</p> Signup and view all the answers

    What is an example of a hospital-acquired infection quality measure?

    <p>Central line-associated bloodstream infections</p> Signup and view all the answers

    What is the reason for the emergency landing of the Boeing 737-900?

    <p>One of the plane engines ingested and burned plastic wrap</p> Signup and view all the answers

    What is the purpose of checklists in healthcare?

    <p>To reduce medication errors</p> Signup and view all the answers

    What is the consequence of a proxy scan in the context of infusion bags?

    <p>The nurse can quickly document the subsequent infusion, but inaccurately</p> Signup and view all the answers

    Why did the nurse have difficulty reading the labels of the infusion bags in the patient's room?

    <p>The lighting in the room was too low</p> Signup and view all the answers

    What is the purpose of the Agency for Healthcare Research and Quality (AHRQ)?

    <p>To evaluate the quality of healthcare</p> Signup and view all the answers

    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.

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