Getting It Right Lecture Questions
Describe two means of flexibility useful for systems where potential
for error and disaster are overwhelming.
- Cross Training
- Decentralization
Describe safety as the cultivation of mindfulness.
- Mindfulness is situational awareness. Cultivating situational awareness is essential to heedful practice.
Describe two elements from aircraft carrier combat operations that
can increase safety in medicine and public safety.
- Blame Free Culture
- Migration of Decision Making
Describe the environment that led to high reliability studies in the
United States Navy and the benefits that resulted.
- Concern over aircraft accidents and resulting loss of life and missions capability resulted in the study and practice
of CRM.
Describe two dangers of leadership in systems with potential for grave
error or disaster.
- Over-assertive leaders.
- Non-consultative styles.
Describe how to recognize and manage unfolding processes that can develop
into disaster.
- Signal detection
- Task saturation.
Contrast management of error as emergent events rather than mistakes.
- Learning from error rather than dispensing punishment.
Describe three elements of safety culture.
- Management committment to safety.
- Communication.
- Workforce committment.
Describe how organizational factors can lead to or reduce unsafe behavior
.
- They can encourage and support safe practice and learning.
Describe variances in culture of hospitals and industry that can lead to
safe and unsafe practices.
- Open culture.
- Reporting culture.
- Willingness to learn.
Contrast open-tree decision algorythms and Boyd-loop decision techniques.
- The algorythm describes a decission tree model that may neglect the trial and error process of the OODA loop technique.
Identify two elements of a system where evidence-based methods would
not apply.
- No opportunity to collect evidence.
- Very low incident rates.
Contrast evidence-based decision systems and objective (or goal)-based
decision systems.
- Empirical evidence-based systems evaluate their performance based on known outcomes. Goal-based decision systems could
actually use empirical-based decision process. They are not incompatible.
- Bortax up vs. Top Dan.
Describe three impediements to instituting high reliability into an
organization.
- Cost reduction.
- Management lack of commitment.
- Legislative concerns.
Describe three naturalistic resources that facilitate instituting high
reliability into an organization.
- Cost saving.
- Life saving.
- Desire to improve.