Patient Safety and Human Factors in Simulation Flashcards

During an in situ simulation in a new emergency department, participants discover the crash cart oxygen tubing does not fit the wall outlet. What is this finding best called?

Answer: A latent safety threat

Latent safety threats are hidden system weaknesses, such as incompatible equipment, that in situ simulation can expose before patients are harmed.

In James Reason's error taxonomy, a nurse who means to give the correct drug but grabs the look-alike vial next to it has made which type of error?

Answer: Slip

A slip is a failure in carrying out a correct plan, often an attention failure such as picking up the wrong vial.

Which intervention sits highest on the hierarchy of safety interventions?

Answer: A forcing function that makes the error physically impossible

Forcing functions and design changes are stronger than education, policies, or labels because they don't depend on human memory or vigilance.

An educator stores simulated medications in a clinical unit for in situ training. Which practice best prevents them from reaching real patients?

Answer: Clearly label them 'For simulation use only, not for human use' and keep them in a separately secured kit

Clear labeling and physical separation of simulated supplies are key safeguards against simulation materials getting into clinical care.

In TeamSTEPPS, what is the purpose of the 'two-challenge rule'?

Answer: To have a team member voice a safety concern at least twice and escalate if it's ignored

The two-challenge rule tells team members to state a concern twice and, if it's still not addressed, to take stronger action or escalate.

In the Systems Engineering Initiative for Patient Safety (SEIPS) model, the work system includes which components?

Answer: Person, tasks, tools and technology, organization, and environment

SEIPS describes the work system as interacting components: person, tasks, tools and technology, organization, and the physical environment.

During a simulated code, a resident keeps reattaching ECG leads while ignoring the fact that the patient is pulseless. Which human factors phenomenon does this show?

Answer: Fixation error

Fixation error is focusing on one task or explanation while missing more critical information.