PS 102

Swiss cheese model of accident causation Serious adverse events are almost always the result of multiple failed opportunities to stop a hazard from causing harm Latent conditions defects in the design and organization of processes and systems — things like poor equipment design, inadequate training, or insufficient resources. These errors are often unrecognized, or just become accepted aspects of the work, because their effects are delayed. Active failures errors whose effects are seen an...

Which of the following is a latent unsafe condition in the system that contributes to the resident's error? Long work schedule To prevent this problem from happening again, which of the following would be the best course of action? Develop a system that prevents messy handwriting from causing miscommunication that leads to error. "Latent errors" are best defined as: Defects in the design and organization of processes and systems What is the active error in this scenario? The nurse adminis...

Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for "units"), and it looks more like an extra zero. As a result, the pharmacist dispenses an insulin dose that's ten times stronger than the patient needs. Which of the following is a latent unsafe condition in the system that contributes to the resident's error? long work schedule T...

Swiss cheese model of accident causation the idea that harm is caused by a series of systemic failures in the presence of hazard. Latent conditions are defects in the design and organization of processes and systems; things like poor equipment design, inadequate training, or insufficient resources. These errors are often unrecognized or just become accepted aspects of the work, and their effects are delayed. Active failures errors whose effects are felt immediately. Active failures are gene...