A staff member discovered a medication with an incorrect label. The staff immediately notified the pharmacist and the correct label was sent prior to
... [Show More] medication administration. Then, the staff completed an event report through the organization's reporting tool.
Which of the following actions should the unit manager take in response to this event?
A.) Document the incident in the employee's performance review.
B.) Investigate system failures and recognize the employee for reporting a near-miss event.
C.) Notify the director of pharmacy about the pharmacist's error.
D.) No action, since the incident did not cause patient harm. - correct answer B.) Investigate system failures and recognize the employee for reporting a near-miss event.
You are educating clinical managers in your health care facility on how to identify appropriate events for conducting a root cause analysis (RCA). Which event provides the BEST opportunity for an RCA?
A.) A post-operative patient removes his own IV, causing a skin tear from the tape.
B.) A patient with no known allergies experiences an anaphylactic reaction to an antibiotic, requiring transfer to ICU.
C.) The biopsy samples from a colonoscopy are never received by pathology after the procedure.
D.) In the last four months, there have been three occurrences of depressed respirations related to sedation in the same department. - correct answer C.) The biopsy samples from a colonoscopy are never received by pathology after the procedure.
A hospital is using the AHRQ Hospital Survey on Patient Safety Culture. There were 80 employees who responded. Responses to the survey item that states "we have patient safety problems in this unit" were as follows:
Strongly Agree: 16
Agree: 32
Neither Agree nor Disagree: 12
Disagree: 17
Strongly Disagree: 3
A.) 75%
B.) 60%
C.) 25%
D.) 20% - correct answer C.) 25%The AHRQ Hospital Survey on Patient Safety Culture User Guide scoring guidance says to use the "Strongly Agree/Agree" response sum, or, for negatively worded items—such as this one—use the "Strongly Disagree/Disagree" sum.
In this example, 17+3 gives us the response sum (i.e., 20), which we divide by total number of respondents (i.e., 80): 20/80 = 25%.
What is one example of a communication technique providers can use to improve communication with patients?
A.) SBAR
B.) Teach-back
C.) CUSP
D.) Two-Challenge Rule - correct answer B.) Teach-back
The Impact of Organizational Change on Safety
What are the three steps to managing patient safety through organizational change?
A.) Monitor change, identify potential safety implications, and employ countermeasures to mitigate any anticipated risks
B.) Employ countermeasures to mitigate any anticipated risks, monitor change
C.) Identify potential safety implications, employ countermeasures to mitigate any anticipated risks, and monitor the change
D.) None of the above - correct answer C.) Identify potential safety implications, employ countermeasures to mitigate any anticipated risks, and monitor the change
What is the term which describes the belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes? - correct answer Psychological safety
A safety-supportive system of shared accountability in which: 1.) Healthcare institutions are accountable for safe systems design and for encouraging safe choices of clinicians and staff (clear expectations set the tone to create environment of mutual respect)
2.) Clinicians and staff are accountable for the quality of their choices (i.e. striving to make the best possible choices as professionals) - correct answer Just Culture
At the conclusion of a surgical procedure at your hospital, the instrument count is incorrect. The hospital policy does not stipulate that the surgeon must remain on the premises until an x-ray is obtained to check for retained foreign objects. By the time the x-ray results come in to reveal that there is, in fact, a retained instrument, the original surgeon has left the hospital to catch a flight. Another surgeon is contacted to remove the retained instrument.
How should leadership respond to this event?
A.) Revise the hospital policy to make it clear that surgeons must stay in the operating room (OR) until instrument count issues are resolved.
B.) Using an appropriate accountability system, counsel the surgeon about customary clinical standards.
C.) Re-educate the OR nursing staff on keeping track of instruments on the sterile field.
D.) Create a process map of how instruments are managed during surgery, looking for latent flaws. - correct answer B.) Using an appropriate accountability system, counsel the surgeon about customary clinical standards.
This term reflects a group of individuals who understand the importance of self- and group- regulation. - correct answer Professionalism
The human resources department at your organization has asked your patient safety specialist for recommendations on new policies to help support safety culture. Which recommendation sounds best?
A.) Sending human resources all event data so that they can record involvement in adverse events in personnel files
B.) Including human resources in all root cause analyses so that they can provide guidance on recommended training updates for staff
C.) Implementing routine use of a tool to determine which events are attributed to human error, at-risk behavior, and reckless behavior
D.) Implementing routine use of a tool to determine which events are attributed [Show Less]