Health Systems and Building Blocks

What are the six building blocks of a health system?

Service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance

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

To improve the health status of individuals, families, and communities

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

By improving the health status of individuals, families, and communities

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

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

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

To respond to a population's needs and expectations in a balanced way 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?

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

What is the primary expectation of healthcare systems by society?

To provide effective and safe care Signup and view all the answers

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

They focus too much on individual errors Signup and view all the answers

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

Many small errors throughout the system 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?

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

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

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

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

Normal accidents Signup and view all the answers

Where do active errors typically occur?

At the point of contact between a human and the larger system Signup and view all the answers

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

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

Why are systems failures often unexpected or unanticipated?

Because of the complexity of systems Signup and view all the answers

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

It is unrealistic Signup and view all the answers

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

Hypomagnesemia Signup and view all the answers

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

A midazolam bag was stocked in the wrong bin Signup and view all the answers

What was the outcome of the adverse event?

The patient experienced respiratory depression and later died Signup and view all the answers

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

The labels on the bags looked similar Signup and view all the answers

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

The scanning process only prompted scanning of the first barcode Signup and view all the answers

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

Administer flumazenil Signup and view all the answers

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

The patient had a DNR order Signup and view all the answers

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

All of the above Signup and view all the answers

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

A pharmacist reported a midazolam bag discrepancy Signup and view all the answers

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

Latent error Signup and view all the answers

What is a characteristic of high-reliability organizations?

Preoccupation with failure Signup and view all the answers

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

Constantly changing conditions Signup and view all the answers

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

Focusing on underlying systems Signup and view all the answers

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

Latent errors Signup and view all the answers

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

They rarely experience safety problems Signup and view all the answers

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

Situational awareness Signup and view all the answers

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

Chronic difficulty scanning infusion bag barcodes Signup and view all the answers

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

A pharmacy technician misplacing the midazolam bag in the magnesium bin Signup and view all the answers

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

Double check Signup and view all the answers

What is the primary goal of the Donabedian Model?

To evaluate the quality of healthcare Signup and view all the answers

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

Central line-associated bloodstream infections Signup and view all the answers

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

One of the plane engines ingested and burned plastic wrap Signup and view all the answers

What is the purpose of checklists in healthcare?

To reduce medication errors Signup and view all the answers

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

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

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

The lighting in the room was too low Signup and view all the answers

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