Swiss cheese is often used as the paradigm for explaining medical error. In this model, the holes
in the cheese represent - Answers✔latent weaknesses
you are assigned to a patient who is at 38 weeks and 6 days gestation. She is being admitted for
an elective induction of labor because her husband is going on as extended business trip in 2
days and he wants to be there fort he deliveery. The hospital has no policy regarding elective
induction, but you know that the AWHONN "Go the full 40" campaign doesn't support early
elective induction. You approach the physician with your concerns. He responds that he's been
doing this for 30 years and has never has a bad outcome from an elective induction at this
gestation. This scenario is an example of: - Answers✔normalization of deviance
Which of the following has been noted among the top 3 root causes of sentinel events for over 10
years: assessment, medication administration, health information technology, or communication.
- Answers✔not assessment
a shared understanding of what is going on and what is likely to happen next is known as -
Answers✔not normalization of understanding
A patient safety event, unrelated to the natural course of the underlying illness, that reaches a
patient and results in death, permanent harm, or severe temporary harm with intervention
required to sustain life is an example of - Answers✔a sentinel event
which tool is used when an adverse event has occurred to identify variations in performance that
led tot he outcome? - Answers✔not case review
Yearly objectives developed by the joint commission that focus on problems in healthcare safety
are known as - Answers✔National Patient Safety Goals
The perinatal care core measures include all of the following except:
1. exclusivity of breast milk feeding
2. elective delivery at > or equal to 37 and <39 completed weeks gestation
3. use of NICHD nomenclature for EFM
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