If you have work experience and know of a change that was made to effect improvement, classify what was done using the VA action hierarchy tool (chapter 9, exhibit 9.3). Analyze the change based on action strength (weaker, intermediate, or stronger) and on the desired or actual outcome. If only weaker actions were taken, what other actions could be added to make the initiative more successful?

Transcribed Image Text:

Strength of Improve- ment Action Weak (reliance on memory/ vigilance) Intermediate Strong (focused on system change) Example of Action Double-checks Warnings and labels New procedure/memorandum/policy Training Additional study/analysis Incentives Warning indicators Supervision Eliminate or substitute system/device Enhanced documentation/communication Redundancy Software enhancements/modifications Increase in staffing/decrease in workload Eliminate/reduce distractions Elimination of look and sound-alikes Readback Training with simulation Architectural/physical plant changes New devices with usability testing before purchasing Engineering control or interlock (forcing functions, environment, work area design) . Leadership/Culture Change Simplify the process and remove unnecessary steps Standardize equipment, processes, protocols, Clinical Guidelines, order sets, coordination of care High reliability testing