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CPPS Review Course final exam
A staff member discovered a medication with an incorrect label. The staff immediately notified the pharmacist and the correct label was sent prior to 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. - 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. - 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% - 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 - 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 - 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? - 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) - 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. - 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. - Professionalism
D.) Offer coaching and apply Just Culture principles to leaders in lower performing areas. - C.) Examine high-performing units to identify and disseminate best practices. 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.) Focus on a list of projects identified by senior stakeholders. C.) Review annual data on defects and successes. D.) Apply best evidence with the goal of failure-free operation over time. - D.) Apply best evidence with the goal of failure-free operation over time. 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.) 30% 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. - C.) 30% of the staff disagree with the statement. The Just Culture model includes creating a learning culture, designing safe systems, and which of the following activities? A.) Providing punishment equal to the harm caused B.) Decreasing the amount of reported errors C.) Finding the individual to blame D.) Managing behavioral choices - D.) Managing behavioral choices Which of the following is the best first step in changing the culture of safety in a health care organization? A.) Conduct an assessment and gather focused data. B.) Develop, policies, procedures, and checklists for safety. C.) Hire an experienced patient safety officer with a strong performance record. D.) Implement communication and teamwork tools. - A.) Conduct an assessment and gather focused data. A nurse on a medical-surgical unit does not comply with the barcode medication administration (BCMA) procedure while caring for one of her patients. Her supervisor is deciding how to respond. As her supervisor, what would you do? A.) Ask the nurse what was occurring at the time, and why she chose to bypass the policy. B.) Counsel the nurse on the importance of following policy
C.) Ask staff if there are adequate scanners to meet their needs. D.) Request that the pharmacy run a report of the BCMA compliance rates of the unit. - A.) Ask the nurse what was occurring at the time, and why she chose to bypass the policy. What are the 3 key areas of Patient Safety leadership? - Strategy, Operations, and Engagement When setting organizational safety priorities, it is best to: A.) Review the current literature to identify areas of frequent concern. B.) Focus primarily on accreditation standards and requirements. C.) Determine priorities based on pay-for-performance measurements. D.) Develop a mechanism to gather input from a variety of sources. - D.) Develop a mechanism to gather input from a variety of sources. A hospital is attempting to engage the board in their quality endeavors. Which is the best strategy to improve the board's involvement? A.) Focus only on measures that are tied to reimbursement. B.) Report all quality measures to the board. C.) Align the quality measures with the hospital's strategic goals. D.) Set only goals that can be attained. - C.) Align the quality measures with the hospital's strategic goals. Which of the following is required to begin the journey to a culture of safety? A.) Care should depend on independent, individual performance excellence. B.) Accountability must be universal and reciprocal, not just top-down. C.) Care should be provider-centered rather than patient-centered. D.) RCA teams must look at errors as individual failures. - B.) Accountability must be universal and reciprocal, not just top-down. 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. - 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. The free, uninhibited flow of information that is open to the scrutiny of others is the definition of:
members, and, upon further investigation, they learned that the issue was common. The findings resulted in the organization replacing the defective devices in all affected areas. Which of the following high-reliability principles did the leaders of this organization apply? A.) Deference to expertise B.) Sensitivity to operations C.) Resiliency D.) Reluctance to accept simple explanations - B.) Sensitivity to operations A patient safety professional wants to ensure engagement of employees in a new patient safety initiative in the hospital. He should: A.) Use staff recommendations for workflow. B.) Collect data on previous initiatives. C.) Communicate the purpose of the initiative to the governing board. D.) Train staff on patient safety principles. - A.) Use staff recommendations for workflow. 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. - B.) Present the story in conjunction with your own facility's data. 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.) Present cases of harm with contributing root causes and actions taken. B.) Highlight system-wide improvements that have been implemented in the past year. C.) Lead an open discussion of board members' safety concerns and recommendations. D.) Display a graph of the numbers and types of safety events reported in the past year.
- A.) Present cases of harm with contributing root causes and actions taken. 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. - 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. Your hospital's leadership is concerned about low safety culture survey scores in the category of "communication openness." The percentage of positive responses related to questioning someone with higher authority is well below national averages. The lead patient safety professional has been asked to make recommendations on increasing the questioning of those with higher authority. To maximize risk reduction, when should staff be asked to stop and question a situation? A.) When something doesn't seem right B.) When a protocol was not followed C.) When discrepancy has been confirmed D.) When patient harm is likely - A.) When something doesn't seem right Hospital leadership has just learned of the reoccurrence of a type of sentinel event that has not occurred in a long time, which they believed to have been permanently resolved. Which of the following possible explanations for the recurrence seems most likely? A.) Negative changes in culture have reduced event reporting B.) Drift to old habits over time has slowly eroded safer practice. C.) Staff are not familiar with safety policies and protocols due to significant turnover. D.) Leadership has stopped messaging on safety because significant time has passed since the last sentinel event. - D.) Leadership has stopped messaging on safety because significant time has passed since the last sentinel event. 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.) See if this is an established pattern for this nurse. B.) Take on the nurse's patients for the rest of the shift. C.) Reassign the nurse's patients to the most senior nurse on the unit. D.) Call a huddle to reassign resources and establish a contingency plan. - D.) Call a huddle to reassign resources and establish a contingency plan. Your hospital implements patient safety WalkRounds as part of a series of changes to improve safety. Six months after the implementation, informal staff feedback suggests inconsistency in the WalkRounds' effectiveness. As the patient safety professional charged with ensuring the success of the effort, what is the best assessment technique to gain insight into current performance? A.) Review information boards in the areas included in the WalkRounds to determine the scope of issues raised. B.) Discuss the informal feedback you have been receiving with the CEO. C.) Gather data about the frequency and content of the WalkRounds to establish current baseline performance.
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.) The contribution of systems factors on the individual's behavior B.) How many years the individual has been practicing C.) The individual's most recent performance review D.) Whether the individual filed a claim with risk management - A.) The contribution of system 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.) Educate all nurses and phlebotomists to ask about patient identifiers before obtaining specimen. B.) Revise the process to allow only one specimen label on the nurse/phlebotomist tray at a time. C.) Standardize the process to require the nurse/phlebotomist to ask the patient to state their name prior to the specimen collection. D.) Utilize barcode scanners to generate a specimen label at the bedside. - D.) 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 calculates the failure modes that will create the most errors. 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 prioritizes the failure modes that do not require action. - 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: A.) Eliminate variation. B.) Help address disruptive behavior. C.) Find the root cause of an incident. D.) Reduce waste. - B.) Help address disruptive behavior TeamSTEPPS can be used to increase communication skills with teams and reduce the risk of miscommunication that can lead to disruptive behavior.In regard to the other answer options: Finding the root cause of an incident is performing a root cause analysis. Reducing waste is Lean process improvement, and eliminating variation is Six Sigma. Your organization utilizes a "home grown" electronic safety event reporting system that is no longer meeting the needs of the organization. Hospital administration is asking for your opinion: What would you do for next steps to identify a replacement system? A.) Purchase the least expensive software. B.) Ask Information Systems to either fix the old system or build a new one. C.) Poll colleagues and purchase what they use. D.) Identify key stakeholders and perform a gap analysis of current state to ideal state. - D.) Identify key stakeholders and perform a gap analysis of current state to ideal state. Performing a thorough search of available products that meet the standards for the organization is the primary action you should take. Once the collated information is obtained, convening a meeting with the key stakeholders (nursing, medicine, finance, patient safety, legal, etc.) to determine the organizational needs in relation to the intended financial impact and return on investment may be required. Your hospital is considering implementing a robotic surgery program. As a patient safety professional, you are concerned about the potential for patient injury associated with this new technology. The most appropriate tool or technique for assessing potential risks associated with implementation of the new technology is: A.) Meaningful use evaluation B.) Failure modes and effects analysis (FMEA) C.) Patient safety leadership WalkRounds D.) Root cause analysis (RCA) - B.) Failure Modes and Effects Analysis (FMEA)The best answer is FMEA.
What is the best strategy or technique to identify and eliminate known and/or potential problems and errors from a system, design, process, and/or service before they occur? A.) Plan-Do-Study-Act (PDSA) B.) Failure modes and effects analysis (FMEA) C.) Define, Measure, Analyze, Improve, and Control (DMAIC) D.) Root cause analysis (RCA) - B.) Failure modes and effects analysis (FMEA) Correct Answer:Failure modes and effects analysis (FMEA)FMEAs are used to proactively mitigate risk and attempt to identify failures before they occur. PDSA is an iterative problem solving model for process improvement. RCA is used in response to an event to attempt to get to the root problem or cause. DMAIC refers to a data-driven improvement cycle. Your organization is preparing to change to a new electronic health record. Many departments have been involved with the planning for this huge effort. What would you suggest as part of the preparation strategy? A.) Suggest a Plan-Do-Study-Act (PDSA) cycle. B.) Offer to do a claims analysis for any related errors. C.) Conduct a failure modes and effects analysis (FMEA). D.) Conduct a root cause analysis (RCA). - C.) Conduct a failure modes and effects analysis (FMEA). Correct Answer:Conduct a failure modes and effects analysis (FMEA).FMEA would be valuable step for anticipating gaps in the planning so that people can address potential problems before implementing the new system. A PDSA cycle would be a good way to test and implement any changes, but it wouldn't help diagnose problems. Patient safety themes linked to improvement of medication adherence by a patient are: A.) Briefs, huddles, and debriefs B.) Leadership, communication, and patient advocacy C.) Patient and family engagement, health literacy, and transitions in care D.) Medication reconciliation, bedside shift report, and nurse double-check - D.) Medication reconciliation, bedside shift report, and nurse double-check Correct Answer:Patient and family engagement, health literacy, and transitions in carePatient and family engagement, health literacy, and transitions in care are patient safety themes to improve medication adherence. Medication reconciliation, shift report, double checks, briefs, huddles, and debriefs are patient safety tools. Leadership, communication, and advocacy are patient safety themes but are not the best choice for themes related to improving medication adherence. A medication error is self-reported by a nurse to the risk manager. The manager tells the nurse to complete an incident report. Upon review of the patient safety event, the manager notices that the nurse overrode a safety check on the barcode scan system. Further review of the "override" report reveals that several other nurses have also
overridden the system. The risk manager further investigates and finds out that there was an issue with the printer in registration on that day, which meant that the barcode scanner could not read the patient ID bracelets. This is an example of what type of analysis? A.) Failure mode and effects analysis B.) Root cause analysis C.) Event report analysis D.) Process analysis - B.) Root cause analysis Correct Answer:Root cause analysis-Root cause analysis is a methodical investigation of the error/event by continuously asking why until you come to the actual cause of the error. Failure mode and effects analysis is usually performed when rolling out something new. Event report analysis is a description of what happened, not necessarily the cause. Process analysis looks at how something is done, rather than why something happened. Which of the following error-reduction strategies is considered the strongest in preventing errors? A.) Fail-safes B.) Education C.) Standardization D.) Checklists - A.) Fail-safes Correct Answer:Fail-safesFail-safes are the strongest strategy to prevent errors because even if the person fails, there is a back-up that keeps the error from occurring. Education relies on memory, so it's a fairly weak strategy. Standardization and checklists are moderate strategies to prevent errors. A new medication administration safety process was implemented in a hospital. A team convened to perform a failure mode effects analysis (FMEA) and calculate a risk priority number (RPN). After a targeted medication safety program on the new process was delivered to nurses, the same team was convened to perform another FMEA. Which of the following would the team be happy to see? A.) The frequency numbers increased and RPNs were lower. B.) The detectability increased and RPNs were lower. C.) The frequency numbers decreased and RPNs were higher. D.) The detectability decreased and RPNs were lower. - B.) The detectability increased and RPNs were lower. Correct Answer:The detectability increased and RPNs were lower.The team would be seeing an improvement if the detectability was higher, meaning safety risks and defects were easier to identify and therefore resolve. It's important to note that detectability has an inverse scale, so higher detectability gets a lower score reflecting lower risk. The RPN represents the overall risk of harm, so improvement would be occurring if that number decreased.
hospital and a hand hygiene awareness campaign. In December 2019, this hospital reports a clostridium difficile infection rate of 4 percent. What conclusion would you draw from this data? A.) The hospital was successful in reducing their clostridium difficile infection rate in
B.) No conclusions can be drawn. C.) Multiple infection prevention efforts are needed to drive down clostridium difficile infection rates. D.) The hospital reduced their clostridium difficile infection rate, though one cannot tell which intervention was most effective. - B.) No conclusions can be drawn.The best answer is that no conclusions can be drawn. Simple comparisons between two values, no matter how easy they are to make or how intuitive they appear to be, cannot fully convey the behavior of data collected over time: both numbers are subject to the common cause variation that is inevitably present in all data. The only way to get a complete picture of what's happening in your organization is to graph data over time, e.g., trended data with multiple data points. Which of the following chart types would be best to demonstrate non-random process variation over time? A.)Control chart B.) Run chart C.) Bar chart D.) Pie chart - A.) Control chartThe best answer is a control chart because it has controls associated with it (both upper and lower control limits) to provide the clearest picture of change over time. Run charts also display change over time but lack the control limits. Bar charts and pie charts are indicative of descriptive statistics and don't allow you to look at something over time or track progress. An organization has implemented measures to provide preventative health screenings in an effort to prevent disease, delay the onset of disease, keep diseases from worsening, and reduce costs to health care. In order to measure effectiveness of the interventions, leaders of the effort are planning to collect data. Which would be the best process measure for them to look at? A.) The number of patients whose pre-existing conditions improved after having been screened B.) The number of patients who reported adopting a healthier lifestyle as a result of the screening C.) Costs to the organization pre and post implementation of the health screenings D.) The number of health screenings performed - D.) The number of health screenings performed. The only process measure among these options is the number of health screenings performed. The rest are outcome (not process) measures.
A recent hospital initiative to decrease venous thromboembolism (VTE) was not successful, despite implementing a training program for staff. An interprofessional team came together to analyze the persistent problem. Pharmacists reported that patients often refused anticoagulant injections, particularly the midnight dose. Nurses reported that patients did not care to be awakened and given an injection, and, other times, nurses withheld the injection because the patient was walking to the bathroom. Which of the following steps is the most important for the team to take to address this problem? A.) Share the data with decision makers and continue to monitor run charts. B.) Use the Plan-Do-Study-Act (PDSA) cycle method for improvement. C.) Require staff to attend an annual training on professional guidelines. D.) Request that pharmacy and nursing brainstorm solutions with their staff. - B.) Use the Plan-Do-Study-Act (PDSA) cycle method for improvement. PDSA cycles can help the team test various ideas for improvement to see which one leads to the best results. Requiring staff to receive more education may not help if the staff are already aware of what they're expected to do and why. Brainstorming solutions may be useful, but it won't lead to improvement without the steps the team would take in conducting PDSA cycles. It's important to monitor the data, but measurement alone does not lead to improvement, as improvement requires change. The leader of a hospital division wants to know if her division's safety (incident) reporting rate is steady or, hopefully, increasing. She is considering using one of the following two data displays: Graph A=Bar Graph Graph B=Control Chart A.) Graph B because it shows many data periods B.) Graph A because it shows volume compared to other divisions C.) Graph A because it shows year-to-date performance D.) Graph B because it shows a report number adjusted for patient volumes - D.) Graph B because it shows a report number adjusted for patient volumes Graph B is the correct answer because it shows a report number adjusted for patient volumes, allowing us to see the true trend of reporting. Using counts to determine whether a reporting volume is steady or rising does not take into account factors that may influence that reporting volume, such as patient census. Using a denominator helps to normalize our interpretation of a count. (Although it is true graph B shows many data points, the same purpose could still be achieved with fewer data points.)Graph A is not correct because this graph reflects count data and only one point in time. (Using Graph A, the division leader may conclude that her division is performing moderately well compared to other divisions, but, again, this graph shows one point in time.) If the bars were a rate of reporting by division (such as by adjusted patient days), the leader could at least determine if there were a comparable rate based on patient volumes.
D.) Medication errors per administered dose on each unit - A.) Medication omissions per administered dose on each unit The patient safety officer has been asked to look at medication omissions, not all medication errors, so medication omissions per administered dose on each unit would be the correct answer. To normalize the data for accurate comparison, the patient safety officer needs to compare rates (as opposed to total numbers). A root cause analysis team has recommended the following action item: "The manager will provide the care team with training on the proper use of personal protective equipment required while caring for a patient with tuberculosis." Which of the following is a process measure the team might use? A.) The number of personal protective equipment purchased B.) The percentage of staff observed to be correctly using personal protective equipment C.) Percentage of staff with positive TB skin tests D.) The number of reported staff exposures to tuberculosis - B.) The percentage of staff observed to be correctly using personal protective equipment The percentage of staff observed to be correctly using personal protective equipment is the best example of a process measure. The other answer options are examples of outcome measures. An example of a descriptive statistics measure for central tendency is: A.) Mode B.) Range C.) Standard error of the mean D.) Standard deviation - A.) Mode Mode is a measure of central tendency. Range, standard deviation, and standard error of the mean are measures of variation. Which of the following is considered to be a scientific method of process improvement for testing a change in a real work setting? A.) Event analysis B.) Root cause analysis (RCA) C.) Failure mode and effects analysis (FMEA) D.) Plan-Do-Study-Act (PDSA) cycle - D.) Plan-Do-Study-Act (PDSA) cycle The PDSA cycle is a scientific method of process improvement that involves planning the change, trying it, observing it, and acting on what is learned. It serves as a guide for testing a change in a real work setting. RCA and event analysis are used mostly in identifying causes related to an adverse event. FMEA is utilized in identifying potential failures before a new process is implemented. Systems thinking encourages organizations to approach cause analysis through:
A.) Recognizing people are fallible and experience errors in which system factors are the major cause B.) Understanding individuals alone need to act reliably and avoid error to make patient care safer C.) Acknowledging the system alone is responsible for safety, and all individual failures indicate a deficiency in the system D.) Identifying and removing poor performers to maintain system performance - A.) Recognizing people are fallible and experience errors in which system factors are the major cause Health care has made strides in realizing errors occur because there are imperfect people working in imperfect systems. Removing "poor performers" without addressing systems issue will not prevent adverse events from recurring; in most cases, there were failures further upstream from the event that allowed it to occur.In regard to the other answer options: Acknowledging the system alone is responsible is inaccurate because, at times, there are individual failures when the system in place did not fail. Telling individuals to "act reliably" will not prevent human error or make systems safer. Referring to the story of the nurse named Karen: Which of the following are human factors issue that contributed to the event? Choose all that apply. Hand-off problems Fatigue Distractions Reliance on memory Look-alike equipment - All of the possible answers are correct. There were hand-off problems and distractions and there was fatigue and reliance on memory.There was also the issue of human nature when Karen first tried to connect the cables; it is human nature to push a little harder when you encounter resistance. Even though there had been some ergonomic and design elements to prevent the cables being connected, with enough force she was able to make the connection.This story does a good job illustrating the system as a whole and how all parts contribute to the outcome. Any shift or change in one of those parts is going to influence the ultimate outcome of that system. Which of the following statements best describes the science of human factors? A.) It is applied to address problems by modifying the design of the system to better aid the people in it. B.) It is about eliminating human error. C.) It consists of a set of principles that can be learned during training. D.) It represents the intersection of medicine and engineering. - A.) It is applied to address problems by modifying the design of the system to better aid the people in it.
