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1 Review the mission, vision, and values of a health care organization, either at the facility or on the facility's website. How do the documents address concern for high reliability and patient safety?

2 While you're at a health care facility, ask a nurse to describe the process in place to report an error, and what happens when an error is reported. Based on what you've learned, is the reporting method focused on learning or blame?

3 Leaders are responsible for creating a culture of high reliability. Review the QSEN competencies outlined in this chapter. During your next clinical rotations, assess the culture of the health care organization. Are the leaders visibly committed to safety? Are nurses involved in process improvements? Is technology used to enhance safety?

4 Review the chapter content related to the Science of Human Error. Why is it important to know if the error is skill‐based, rule‐based, or knowledge‐based? Which types of errors have you made, in your personal or professional life? What tools would help prevent these errors?

5 Review the chapter content related to the I PASS the BATON and SBAR communication tools. The next time you are providing care, try using one of these tools in your handoff to another provider. Did the tool help you to organize your thoughts more concisely? Did it prompt you to share the most pertinent information?

6 The government and other organizations are mandating public reporting for health care safety, quality, and financial indicators. How does this transparency influence quality and safety? What nursing resources are available to assist a health care organization on the road to high reliability? What interprofessional resources are available?