Which report is thought to have launched the current patient safety movement? -
ANSWERS-The IOM's Committee on Quality of Care in America report called 'To
Err is Human: Building a Safer Health System' issued in 1999 published by the
National Academies Press in 2000
QUESTION 2
Focus of voluntary reporting systems - ANSWERS-Focus on a much broader set of
errors, mainly those that do no or minimal harm, and help detect system
weaknesses that can be fixed before the occurrence of serious harm.
QUESTION 3
How is it proposed to foster participation on voluntary reporting systems? -
ANSWERS-Congress should enact laws to protect the confidentiality of certain
information collected to alleviate the fears that such information may be
subpoenaed and used in lawsuits.
END OF
PAGE 1
, ABQUARP exam 2024
QUESTION 4
What was learned from the aviation industry? - ANSWERS-Reinforcing current
approaches to training and pressuring pilots to be more careful would not improve
safety. Much of aviation's safety improvement came from applying principles of
social and cognitive psychology and human factors engineering to its own
challenging work environment.
QUESTION 5
Human factors engineering contributes to safety through: - ANSWERS-
understanding the interrelations between humans, the tools they use, and the
environment in which they live and work
QUESTION 6
Difference between complicated and complex systems: - ANSWERS-Complicated
systems may include multiple individuals, supplies, and steps, but function
predictably, such as is seen on an assembly line or can be mapped in a flow chart.
In complex systems, where interrelationships among individuals, technology, and
other aspects of the environment affect each other and are continually changing,
safety improvement never ends. A change in one part of the system may create
unintended hazards somewhere else.
END OF
PAGE 2
, ABQUARP exam 2024
QUESTION 7
Important point brought home by the Swiss Cheese Model: - ANSWERS-Multiple
failures are all necessary and only jointly sufficient to let the hazard reach the place
it should not be.
QUESTION 8
Marx's levels of accountability: - ANSWERS-Human Error: includes inadvertent
mistakes and should be managed by consoling individual and making changes to
processes, procedures, training, and design
QUESTION 9
At-risk behavior: includes choices involving risk that is not recognized or justified.
This should be managed by coaching the individual and rewarding healthy
behavior, not at-risk behavior.
QUESTION 10
Reckless behavior: includes conscious disregard of unreasonable risk. In this case
remedial and punitive actions are appropriate.
END OF
PAGE 3
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