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CPPS IHI Practice Exam
In preparation for new antimicrobial stewardship regulatory requirements, a hospital is creating an antimicrobial stewardship committee. What should be the first step in supporting this new patient safety initiative? A. Reach out to subject matter experts to gain insight on different compliance issues. B. Work with information technology (IT) to build antibiotic indication and time-out screens. C. Partner with key stakeholders to perform a gap analysis of current state to ideal state. D. Review the past year's data to identify the most commonly grown pathogens. Correct Answer: C. Partner with key stakeholders to perform a gap analysis of current state to ideal state. After implementing a new product recall system, a hospital was alerted to a high-risk medication recall. This medication is in stock in the emergency department and oncology unit. To ensure the effectiveness of the new system, a patient safety professional should: A. require individual departments to verify that a search for the recalled medication was performed. B. ensure an on-site visit verifies that the recalled medication was sequestered. C. reconcile the number of doses administered to the number of doses purchased. D. notify the affected units via fax to remove recalled meds and to post recall notices in the units Correct Answer: B. ensure an on-site visit verifies that the recalled medication was sequestered. An organization is implementing a standardized surgical safety checklist and encounters resistance from the perioperative staff. To improve staff engagement, a patient safety professional should: A. prepare a business case for the implementation of the checklist. B. present evidence that checklist use reduces practice variability. C. assure staff that anesthesia is responsible for the checklist. D. delegate checklist enforcement to nursing. Correct Answer: B. present evidence that checklist use reduces practice variability. An organization has achieved 92% compliance with a process measure. The patient safety professional believes that the processes in place are not reliable or that the results are attributable to luck. Which of the following best describes this characteristic? A. appreciative inquiry B. commitment to resilience C. deference to expertise D. preoccupation with failure Correct Answer: D. preoccupation with failure A just culture framework provides a means to address behaviors that undermine a culture of safety because A. single outbursts are differentiated from consciously chosen acts. B. preservation of highly valued team members is a primary goal. C. the evaluative process does not consider personal performance-shaping factors. D. the organizational response to investigated events is independent of patient outcome. Correct Answer: D. the organizational response to investigated events is independent of patient outcome. In process improvement, reducing variation improves A. predictability of outcomes.
B. patient care processes. C. frequency of poor results. D. reluctance to simplify. Correct Answer: A. predictability of outcomes. When creating action plans, which of the following solutions would be considered the weakest? A. visible involvement and action by leadership B. standardizing processes as much as possible C. creating access barriers to high-risk medications D. use of color-coded labels that are readily seen by staff Correct Answer: D. use of color-coded labels that are readily seen by staff Which of the following is emphasized in crew resource management? A. care standards B. team leadership C. caregiver burnout D. health literacy Correct Answer: B. team leadership
As a result of an adverse drug event, a patient required renal dialysis. A patient safety professional and other leaders are discussing what to disclose to the patient. In addition to an apology, critical components of disclosure include A. a commitment to investigate what happened and how future errors will be prevented. B. who was involved, when it happened, and how often medication errors occur. C. plans for staff disciplinary action, physician disciplinary action, and a plan for education. D. history of pharmacy transcription errors, and the plan to implement an electronic health record. Correct Answer: A. a commitment to investigate what happened and how future errors will be prevented. Results from recent tests were not included in a patient transfer from one facility to another, resulting in an adverse event. Which of the following is the most common cause of this type of harm? A. inadequate information flow B. inattentional blindness C. normalized deviance D. insufficient staffing Correct Answer: A. inadequate information flow A healthcare organization is introducing a new medication administration barcoding system. Which of the following is the most significant indicator of successful implementation? A. order accuracy for high-risk medications B. bar code scanning compliance C. nursing bar coding knowledge D. bar coding performance goal setting Correct Answer: B. bar code scanning compliance A manager demonstrates adherence to the principles of a just culture by applying which of the following types of decision-making frameworks? A. harm-based B. outcome-focused C. equity-focused D. risk-based Correct Answer: D. risk-based
C. requiring providers and staff to complete a safety training program. D. collaborating with providers and staff to strengthen the screening process. Correct Answer: D. collaborating with providers and staff to strengthen the screening process. Which of the following statements about root cause analysis (RCA) is accurate? A. The goal of performing an RCA is to find the one underlying root cause. B. RCAs are not subject to outcome or hindsight biases. C. RCAs may be subject to political highjack, resulting in poor risk controls. D. RCAs are as effective in healthcare as they are in other high-risk industries. Correct Answer: C. RCAs may be subject to political highjack, resulting in poor risk controls. Which of the following is accurate when a patient has back-to-back procedures, and the person performing each procedure changes? A. No staff changes may occur between procedures. B. One time-out at the beginning of the first surgery is sufficient for each procedure. C. Another time-out needs to be performed before starting each procedure. D. No additional sponge count is needed between surgeries. Correct Answer: C. Another time-out needs to be performed before starting each procedure. Which of the following is most useful in illustrating inefficiency and waste in a process? A. fishbone diagram B. control chart C. spaghetti chart D. Pareto diagram Correct Answer: C. spaghetti chart Measurement of hospital-acquired pressure injuries would be an example of A. an outcome measure. B. a process measure. C. a balance measure. D. an evidence-based measure. Correct Answer: A. an outcome measure. What type of organization recognizes and respects that information can come from any source within the organization and that each reporter has a valuable perspective? A. highly reliable B. diverse C. patient-centered D. interdisciplinary Correct Answer: A. highly reliable From a human factors engineering perspective, which of the following should beknown about identifying and eliminating diagnostic errors? A. Diagnostic errors are the result of cognitive biases and failures by clinicians. B. Partnership with scientists in cognition, perception, and decision making is needed. C. An effective strategy to reduce diagnostic errors is the use of checklists. D. Attribution of diagnostic errors is not subject to either hindsight or outcome biases. Correct Answer: B. Partnership with scientists in cognition, perception, and decision making is needed. Which of the following would best demonstrate non-random process variation over time? A. histogram
B. control chart C. run chart D. pie chart Correct Answer: B. control chart A patient safety professional is leading a process improvement team to enhance communication hand- offs between hospital units. Which of the following is the best question to ask at the first team meeting? A. "What process change should be the focus?" B. "When should direct observations begin?" C. "What are we trying to accomplish?" D. "When should we spread best practices?" Correct Answer: C. "What are we trying to accomplish?" Which of the following is most important in building a culture of safety? A. measuring safety outcomes B. addressing burnout C. establishing shared values D. utilizing electronic health records Correct Answer: C. establishing shared values A practitioner reads a groundbreaking study on a condition seen frequently in their practice. Coincidentally, the next patient that the practitioner sees has symptoms commonly seen with that condition. Which of the following biases or heuristics best describes this phenomena? A. anchoring B. availability C. premature closure D. risk aversion Correct Answer: B. availability While investigating a near miss medication event, a manager identifies a pattern of work arounds by a clinician that violates policies and procedures. To determine accountability, the manager's next step should be to A. conduct a focus group with work area staff. B. perform a substitution test. C. escalate the workarounds to leadership. D. amend procedures to support the workarounds. Correct Answer: B. perform a substitution test. A physician is planning to discharge a patient. The nurse knew that the patient needed additional equipment at home. Together they reached out to the social worker and discharge planner for a safe care transition. Which feature of the culture of safety did they practice? A. activation of transfer protocols B. utilization of open communication C. measurement of patient safety D. ensuring health literacy Correct Answer: B. utilization of open communication From a human factors standpoint, which of the following is true about harmduring healthcare? A. It is either due to system errors or intentional human choice. B. It would not occur if healthcare workers followed rules. C. It is prevented by healthcare workers adapting to changes. D. It is always preventable; the goal is zero harm. Correct Answer: C. It is prevented by healthcare workers adapting to changes.
B. careless action. C. at-risk behavior. D. recklessness. Correct Answer: A. human error. Which of the following actions provides evidence that a healthcare organization considers patients' experiences to improve the safety of patientcare? A. Consumers, payors, and administrators are represented on committees. B. Patients receive experience surveys after reviewing charges. C. Patient feedback is used to redesign care processes. D. Patient involvement is publicly recognized. Correct Answer: C. Patient feedback is used to redesign care processes. A new long-term care facility is being planned. Recognizing that resident injuries related to falls are a significant concern, a team has been convened to plan, implement, and evaluate potential solutions. Which of the following interventions will have the largest impact on the rate of injuries related to falls? A. Position grab bars in bathrooms. B. Attach egress alarms to residents. C. Locate floor pads next to beds. D. Install impact-absorbing flooring. Correct Answer: D. Install impact-absorbing flooring. The patient safety professional disseminated a patient safety culture survey to all employees at a 100- bed hospital. The total response rate was 32%. Which of the following should the patient safety professional do next? A. Re-survey the staff to obtain a higher response rate. B. Form a task force to address the questions on the safety survey. C. Interpret the results with caution due to the response rate. D. Contact the managers of the units to identify non-responders. Correct Answer: C. Interpret the results with caution due to the response rate. On studying the results of a root cause analysis, it is recognized that an RN missed steps in a protocol. The RN is regarded as highly competent by colleagues and unit leaders. The patient safety professional should determine the RN's behavior in this error to be considered A. workaround. B. reckless. C. high risk. D. drift. Correct Answer: D. drift. Patient safety is considered a subset of quality, but it is more difficult to measure in part because A. identification of incidents often depends on self-reporting. B. caregivers are not held accountable to report incidents. C. incident reporting systems are always anonymous. D. of dependence on trigger tools to identify safety events. Correct Answer: A. identification of incidents often depends on self-reporting. Leadership addressed an unrecognized latent threat in an existing workflow that was brought to their attention by frontline workers. This is an example of: A. preoccupation with failure. B. decentralized decision making.
C. sensitivity to operations. D. commitment to resilience. Correct Answer: C. sensitivity to operations. Leadership has been promoting fair and just culture concepts including non-punitive response to reporting and the value of near miss reporting. The plan is not universally supported, and some argue it is a waste of the facility's resources. To support this leadership initiative, a patient safety professional should explain that the plan is intended to result in A. a decrease in event reporting volume due to fewer actual adverse events. B. a decrease in event reporting due to fewer near misses. C. an increase in event reporting that will decrease malpractice insurance premiums. D. an increase in event reporting that will help the hospital identify areas of risk. Correct Answer: D. an increase in event reporting that will help the hospital identify areas of risk. Which of the following is the most appropriate method to determine if a root cause analysis (RCA) should be conducted on an adverse event? A. Consider only the outcome severity. B. Consider only blameworthy events. C. Utilize a risk-based prioritization system. D. Assess only the probability of recurrence. Correct Answer: C. Utilize a risk-based prioritization system. Which of the following strategies is best for facilitating the acceptance of changer elated to specific performance improvement initiatives? A. Provide a quarterly statistical report. B. Utilize storytelling tools. C. Recognize leadership participation. D. Distribute weekly newsletters via e-mail. Correct Answer: B. Utilize storytelling tools. A patient who is a heroin addict and frequent visitor to the emergency department presented to the hospital with abdominal pain, nausea, and vomiting. He was admitted for dehydration and potential opioid withdrawal. The patient's abdominal pain worsened at night, prompting the nurse to call the physician on call. The physician assumed that the patient was drug-seeking, and increased the patient's methadone. Early the next morning, the patient experienced severe abdominal pain, showed signs of sepsis, and was found to have an abdominal perforation. Which cognitive process best describes the on- call physician's response? A. hindsight bias B. implicit bias C. normalization of the deviant D. recall bias Correct Answer: B. implicit bias 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
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. Re-educate the OR nursing staff on keeping track of instruments on the sterile field. B. Revise the hospital policy to make it clear that surgeons must stay in the operating room (OR) until instrument count issues are resolved. C. Using an appropriate accountability system, counsel the surgeon about customary clinical standards. D. Create a process map of how instruments are managed during surgery, looking for latent flaws. Correct Answer: C. Using an appropriate accountability system, counsel the surgeon about customary clinical standards. The surgeon made a choice to leave for personal reasons before receiving confirmation that his patient was safe. In the substitution test, other surgeons would likely consider it their responsibility to stay and assure the patient was object-free.Although the policy could clearly outline that a surgeon must stay until counts are confirmed, it is unrealistic for leaders to regulate every step of every process and practice: As health care professionals, surgeons already have a pre-existing, overarching duty to avoid causing unjustifiable risk or harm. In this case, counseling the surgeon likely does not mean pulling his privileges; it means having a conversation with him about the inappropriateness of the action he took and the potential impact on his patient. Sometimes individuals do share the responsibility for a deviation, and we need to hold professionals accountable for their portion of a situation even when system factors may also need improvement. 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 to human error, at-risk behavior, and reckless behavior AND consulting with human resources on at-risk and reckless behavior cases Correct Answer: C. Implementing routine use of a tool to determine which events are attributed to human error, at-risk behavior, and reckless behavior AND consulting with human resources on at-risk and reckless behavior cases The first answer (sending human resources all event data so that they can record involvement in adverse events in personnel files) is incorrect because including all events in personnel files regardless of blame worthiness does not support a just culture. The second answer (including human resources in all root cause analyses so that they can provide guidance on recommended training updates for staff) is interesting but incorrect because recommendations for staff training could come out of the RCA process without the involvement of HR. The third answer (implementing routine use of a tool to determine which events are attributed to human error, at-risk behavior, and reckless behavior) is not correct because, while it makes the good suggestion of using a tool to distinguish among human error, at-risk behavior, and reckless behavior, it does not address what to do with that information; human resources should be consulted to help determine fair consequences for blameworthy events — this makes the fourth answer the best.
In which of the following activities would a patient safety specialist engage to promote a culture of safety? A. Instruct team members to act in a safe and respectful manner. B. Apply best evidence with the goal of failure-free operation over time. C. Review annual data on defects and successes. D. Focus on a list of projects identified by senior stakeholders. Correct Answer: B. Apply best evidence with the goal of failure-free operation over time. In the IHI Framework for Safe, Reliable, and Effective Care, the role of patient safety specialists is to apply best evidence with the goal of failure-free operation over time. This involves reviewing data frequently (much more often than annually), designing systems to help people make the right choice (rather than relying on education to change behavior), and setting priorities in collaboration with senior stakeholders (rather than solely at their direction).
- At the end of a long, exhausting shift, an experienced nurse administered the wrong medication by picking up the wrong syringe. The wrong medication was an analgesic, and the patient didn't suffer any problems. After recalling that his colleague was fired last month over a medication error, he decides not to file an incident report. Safety culture would be improved if the hospital provided this employee with which of the following? A. An electronic reporting system B. Psychological safety C. Situational awareness training D. Training on reporting Correct Answer: B. Psychological safety In this case, regardless of whether the nurse has the knowledge or ability to report the error, he is not speaking up because he does not feel psychologically safe to do so. If the nurse felt psychologically safe, he would feel confident that his concern would be heard and that appropriate, system-focused action (as opposed to misplaced blame and punishment) would ensue. A staff nurse at your hospital fails to complete a double-check before administering a high-alert medication. She gives the medication to the incorrect patient, and the patient suffers an arrhythmia. When applying James Reason's unsafe acts algorithm, what is a strategy to use prior to holding the nurse personally accountable? A. Hold a root cause analysis. B. Perform the substitution test with three other nurses. C. Ask other nurses if the staff nurse is trustworthy. D. Have the chief nursing officer interview the nurse. Correct Answer: B. Perform the substitution test with three other nurses. Performing the substitution test, which entails asking other professionals if they would be likely to repeat the same behavior if placed in the same situation, is an effective way to assess whether a blameworthy event has occurred. In this case, if other individuals say they might have also skipped the double-check, it is fair to assume there is an underlying systems issue at fault for the nurse's actions, and she should not be held personally accountable. The other options listed are not reasonable methods to discern whether the problem is a systems issue or a blameworthy personnel issue.
- To improve culture of safety survey results, which of the following should an organization do? A. Offer coaching and apply Just Culture principles to leaders in lower performing areas.
D. Implement communication and teamwork tools. Correct Answer: C. Conduct an assessment and gather focused data. As a first step in improving the culture, an assessment and data review are necessary to determine the current strengths and weaknesses of the organization. Once strengths and weaknesses are identified, then focused action plans can be developed for improvement. (New policies and procedures and/or communication and teamwork tools could be part of the action plans). Having a patient safety officer is important but not as central to the improvement effort as the data. As your organization's patient safety officer, you are reviewing unit results on the AHRQ Culture of Safety Survey. You are speaking with the manager of a unit for which the unit percent positive score is 30 percent for the following statement: "Staff in this unit work longer hours than is best for patient care." What do you tell the manager the positive answer in this statement means? A. 0% of the staff agree with the statement. B. 30% of the staff work longer hours. C. 30% of the staff disagree with the statement. D. 70% of the staff work longer hours. Correct Answer: C. 30% of the staff disagree with the statement. The percent positive score refers to answers that reflect the presence of patient safety. In this case, the question is asking about a risk to patient safety, so the responses of "agree" and "strongly agree" are negative responses for patient safety. The percent positive score of 30% means that 30% of the staff disagreed with this statement, thereby saying that patient safety is present. When setting organizational safety priorities, it is best to: A. Determine priorities based on pay-for-performance measurements. B. Develop a mechanism to gather input from a variety of sources. C. Review the current literature to identify areas of frequent concern. D. Focus primarily on accreditation standards and requirements. Correct Answer: B. Develop a mechanism to gather input from a variety of sources. In order to understand the variety of safety issues that an organization faces, it is best to solicit concerns from a variety of sources. Focusing primarily on performance measurements or accreditation requirements will not identify or address the full range of possible priorities. Having information from a variety of sources will ensure all areas of importance are captured. A hospital is attempting to engage the board in their quality endeavors. Which is the best strategy to improve the board's involvement? A. Align the quality measures with the hospital's strategic goals. B. Set only goals that can be attained. C. Focus only on measures that are tied to reimbursement. D. Report all quality measures to the board. Correct Answer: A. Align the quality measures with the hospital's strategic goals. If quality/safety measures are aligned with the hospital's strategic goals, this assures that everyone across the system, from the board to the frontline staff, have quality and safety as a point of focus. Reporting all quality measures to the board is too broad and not practical; measures across the system should be rolled into fewer overarching strategic measures that the board can reasonably review.Focusing only on measures that are tied to reimbursement might be a barrier to aligning your
quality measures with strategic initiatives, and it could lead to neglect of important areas for improvement. (Notably, the list of outcome measures that the Centers for Medicare & Medicaid Services ties to reimbursement consistently grows; if you focus only on measures currently tied to reimbursement, you could fall behind.)Setting only goals that can be attained is incorrect because it would encourage average performance rather than continuous improvement and excellence. Which of the following is required to begin the journey to a culture of safety? A. RCA teams must look at errors as individual failures. B. Care should be provider-centered rather than patient-centered. C. Care should depend on independent, individual performance excellence. D. Accountability must be universal and reciprocal, not just top-down. Correct Answer: D. Accountability must be universal and reciprocal, not just top-down. A just culture maintains standards of universal and reciprocal accountability. A just culture also favors patient-centered (as opposed to provider-centered) care; encourages interdependency, collaboration, and inter-professional teamwork; and believes that the causes of most errors can be traced to system failures. You are meeting with your organization's CFO to review the likely Return on Investment (ROI) for several possible patient safety initiatives. Based only on the projected ROI, which project is most likely to receive the CFO's approval? A. Implementation of Computerized Provider Order Entry to reduce the number of medication errors with an ROI of 1.0, or 100 percent. B. Procurement of new beds with built-in alarms to reduce falls with an ROI of 0.9, or 90 percent. C. Implementation of evidence-based guidelines to reduce the rate of catheter-associated urinary tract infections with an ROI of 3.0, or 300 percent. D. Implementation of a sitter program, which has been shown to reduce falls and improve patient satisfaction with an ROI of 0.5, or 50 percent. Correct Answer: C. Implementation of evidence-based guidelines to reduce the rate of catheter-associated urinary tract infections with an ROI of 3.0, or 300 percent. With an anticipated ROI greater than 100 percent, reducing catheter-associated urinary tract infections is most likely to receive the CFO's approval based on the ROI alone. Which of the following tactics is the best approach to increase near-miss event reporting? A. Include staff names in event reports. B. Give staff up to a week to report events. C. Require staff to report all errors and near-misses. D. Provide event reporters with feedback and follow-up. Correct Answer: D. Provide event reporters with feedback and follow-up. The most important reason for staff to report safety events is because they believe the information will be used to make care safer. If leaders do not provide feedback and follow-up about what is being done in response to an event report, staff are unlikely to continue to report, even if other incentives are in place.
of a root cause analysis. Staff members are "second victims" and usually should be supported and not blamed when an adverse events occurs. Which of the following changes to operations would best highlight leadership's commitment to patient safety? A. Implementing quarterly town hall meetings to share organizational information B. Executive leadership regularly participating in leadership rounds and daily safety briefings C. The hospital executive reporting on patient safety at every board meeting D. Including an executive representative on all root cause analysis teams Correct Answer: B. Executive leadership regularly participating in leadership rounds and daily safety briefings While all answers show a level of leadership commitment to safety, having executive leadership regularly participating in rounds and briefings is the best answer because it provides an opportunity for frontline staff to interact with senior leadership on a regular basis. In addition, by attending daily safety briefings, the senior leader stays engaged and aware of safety issues within the organization. A patient safety professional wants to ensure engagement of employees in a new patient safety initiative in the hospital. He should: A. Collect data on previous initiatives. B. Train staff on patient safety principles. C. Communicate the purpose of the initiative to the governing board. D. Use staff recommendations for workflow. Correct Answer: D. Use staff recommendations for workflow. Using staff recommendations for workflow improves employee engagement by providing a sense of ownership over the initiative. Communicating the purpose of the initiative to the governing board enhances leadership support and commitment, not employee engagement. Your patient safety team performs a root cause analysis on a recent wrong-side surgery event. Which of the following action items reflects the highest level of reliability? A. Change the color of surgical site markers from black to red. B. Implement a process in which the surgical technician holds the scalpel (and does not hand it to the surgeon) until a timeout with all team members at attention has taken place. C. Educate surgeons to be present for surgical timeouts. D. Every month, perform multidisciplinary simulations empowering all staff to speak up for safety. Correct Answer: B. Implement a process in which the surgical technician holds the scalpel (and does not hand it to the surgeon) until a timeout with all team members at attention has taken place. A process that pauses the surgery until all team members have participated in a timeout to confirm essential details of the surgery, including the correct side to operate on, is the highest reliability feature because it stops the process until safety checks have been performed. Training still relies on individual behavior to protect safety, which is not as reliable as a process that requires a timeout to proceed. Changing the color of the site marker does not ensure that the mark will be made on the correct side. You are the charge nurse on a busy ICU. It is 11:00 PM, and one of your nurses needs to leave for a family emergency. Which of the following actions is the most appropriate next step? A. Take on the nurse's patients for the rest of the shift. B. Reassign the nurse's patients to the most senior nurse on the unit.
C. See if this is an established pattern for this nurse. D. Call a huddle to reassign resources and establish a contingency plan. Correct Answer: D. Call a huddle to reassign resources and establish a contingency plan. The best answer is to call a huddle, which is an appropriate option for ad hoc planning. During the huddle, the team can reestablish situational awareness, confirm the plans already in place, and assess the need to adjust the plan.An established pattern of absenteeism is more of an HR issue than a patient safety issue. The pros and cons of the other options, including the charge nurse taking on the patients (which would leave the team without a leader) or the most senior nurse (who may already have the most patients) taking on extra patient patients, can be discussed at the huddle. The free, uninhibited flow of information that is open to the scrutiny of others is the definition of: A. Just Culture B. Transparency C. Quality care D. High reliability Correct Answer: B. Transparency The Lucian Leape Institute defines transparency as the free, uninhibited flow of information that is open to the scrutiny of others. The other three options would not be so defined. In cause analysis, the role of the Executive Sponsor is to: A. Prepare for a visit by the department of health if the event meets criteria for reporting to the state. B. Complete the initial debrief following a patient safety event and ensure the safety of all involved. C. Coordinate all efforts of the cause analysis team and conduct performance management discussions. D. Help scope the objectives and maintain accountability for effective and timely action plans. Correct Answer: D. Help scope the objectives and maintain accountability for effective and timely action plans. Completing the initial debrief describes the role of the department manager or leader. Preparing for a visit by the department of health is the responsibility of the regulatory staff, and coordinating all efforts of the cause analysis team speaks to responsibilities of the cause analysis facilitator and department manager. The Executive Sponsor can help establish the team charter, ensure adequate resources, and attend cause analysis meetings as appropriate. A medication error at a nearby hospital has recently received media attention. In examining your own organization, you find similar processes are in place to the ones that contributed to the error. You'd like to change your hospital's processes but worry people will be resistant to change. What would be the best method to use to influence others as to the need for change? A. Reference accreditation standards and hospital policy as the need to make a change in process. B. Present the story in conjunction with your own facility's data. C. Develop a staff recognition program for reporting actual events that occur in your facility. D. Conduct a root cause analysis on a similar event that has occurred at your own facility. Correct Answer: B. Present the story in conjunction with your own facility's data. Effectively modifying behavior and developing acceptance of workplace changes requires a multifaceted approach, and storytelling and quantitative analysis are important aspects of effective calls to action. Some experts suggest that more than one method of communication is necessary to be truly effective. The other answers represent actions that could be taken depending on the specific issue; however, providing a motivational story and your own facility's data would likely be most effective in this scenario.
workplace changes, but particularly with the implementation of new reporting systems.With regard to the other possible answers: Senior leaders should be involved with the decision-making process but should not necessarily provide exclusive input on the decision. The "Request for Proposal" may be an important part of an organization's evaluation process but should not be the sole input into the recommendation process. Finally, conducting benchmark evaluations can be helpful, but the simple tally described is too simplistic to determine a software recommendation. You have been asked to present an overview of safety events to your hospital's board of trustees. In order to best represent safety issues, you should: A. Lead an open discussion of board members' safety concerns and recommendations. B. Display a graph of the numbers and types of safety events reported in the past year. C. Present cases of harm with contributing root causes and actions taken. D. Highlight system-wide improvements that have been implemented in the past year. Correct Answer: C. Present cases of harm with contributing root causes and actions taken. The board of trustees maintains ultimate responsibility for the quality and safety of care provided. It is important that the board be aware of the harm that occurs within the facility, the systemic issues that may have caused or contributed to that harm, and the actions taken to prevent or mitigate the risk of harm. A patient safety professional wants to enhance a culture of reporting by introducing a visual tool that quickly provides the opportunity for frontline staff to share defects, promote their risk awareness, and share in resolution of defects. The most suitable tool is: A. Learning boards B. Patient safety leadership WalkRounds C. Root cause analysis D. Failure modes and effects analysis Correct Answer: A. Learning boards A learning board is a visual tool that enhances frontline staff participation in the resolution of defects. The other options to do meet the criteria mentioned: Failure modes and effects analysis is a proactive tool for risk assessment. Root cause analysis happens after reporting. Patient safety leadership WalkRounds are not a visual tool. Your health system learns about an incident involving a retained sponge following surgery, and an RCA will be performed. The root cause analysis is credible if: A. It is reviewed and signed by a patient safety professional. B. Corrective actions have been developed and completed. C. A single, clearly defined root cause has been identified. D. There is participation by leadership and individuals closely involved in the process. Correct Answer: D. There is participation by leadership and individuals closely involved in the process. The Joint Commission Comprehensive Accreditation Manual for Hospitals states that RCAs for sentinel events, such as this, will be considered acceptable if they are thorough and credible with "credible" defined as: 1) including participation by leadership and individuals most closely involved in the process and 2) internally consistent (i.e., the RCA does not contradict itself).
A team is reviewing a serious harm event through the root cause analysis process. Before it draws any conclusions about the accountability of the provider(s) involved, what elements should the team consider? A. How many years the individual has been practicing B. Whether the individual filed a claim with risk management C. The individual's most recent performance review D. The contribution of systems factors on the individual's behavior Correct Answer: D. The contribution of systems factors on the individual's behavior. The contribution of systems factors on the individual's behavior reflects just culture principles and the proper approach to use before drawing conclusions about accountability. A hospital's patient safety team is exploring strategies to reduce the number of patient identification errors in the lab specimen collection process. Which of the following strategies will provide the highest impact in reduction of errors? A. Revise the process to allow only one specimen label on the nurse/phlebotomist tray at a time. B. Educate all nurses and phlebotomists to ask about patient identifiers before obtaining specimen. C. Utilize barcode scanners to generate a specimen label at the bedside. D. Standardize the process to require the nurse/phlebotomist to ask the patient to state their name prior to the specimen collection. Correct Answer: C. Utilize barcode scanners to generate a specimen label at the bedside. Utilizing bar code scanners is the correct answer because it entails a forcing function at the bedside. After scanning the armband, the correct label for that patient will print from the scanner. In regard to the other options: Education is always the lowest impact (soft fix) in any action plan. Changing processes is better but will still rely on individuals to do the right thing, e.g., the nurse/phlebotomist would need to make sure multiple labels were not on the tray, which is a common shortcut to avoid having to walk back and forth between specimen collections. Direct observation would be required to make sure people didn't introduce workarounds. In the context of failure modes and effects analysis (FMEA), how is the risk priority number (RPN) used? A. It prioritizes the failure modes that do not require action. B. It specifies the failure modes that have been shown to cause harm. C. It identifies the highest priority failure modes to address. D. It calculates the failure modes that will create the most errors Correct Answer: C. It identifies the highest priority failure modes to address. The Risk Priority Number (RPN) is a score that provides the team a way to identify the highest risk failure modes in descending order. If the team does not have the resources to address all the identified risks, this number can be used to filter out failure modes that are acceptable in the current state.In regard to the other answer options: The RPN does not determine that an action is not required; that determination comes from the team evaluating the issue at hand, and, to some degree, may be decided based on time and resources available. The RPN does not identify error potential or represent harm that has already occurred; it identifies the impact of a failure mode if it does occur. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is a process improvement program that can be used to:
