Identifying and Mitigating Medical Errors and Patient Safety Risks, Exams of Nursing

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Certified Professional In-Patient Safety Exam

Questions and Answers 2 024

iatrogenesis - answer Greek for originating from a physician preventable adverse events - answer those that occurred due to error or failure to apply an accepted strategy for prevention Ameliorable adverse event - answer events that, while not preventable, could have been less harmful if care had been different adverse events due to negligence - answer those that occurred due to care that falls below the standards expected of clinicians in the community near miss - answer an unsafe situation that is indistinguishable from a preventable adverse event except for the outcome - exposed but does not experience harm either through luck or early detection error - answer broader term referring to any act of commission or omission that exposes patients to a potentially hazardous situation adverse event - answer An injury caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced at disability at the time of discharge, or both commision - answer doing something wrong omission - answer failing to do the right thing CPOE - answer Computerized Provider Order Entry 2009 HITECH Act and meaningful use program computer alerts three main findings - answer 1. modestly effective at best

2. alert fatigue is common
3. fatigue increases with exposure and heavier use of CPOE systems minimize alert fatigue - answer 1. increase alert specificity to reduce inconsequential alerts
4. tier alerts according to severity
5. make only high level/severe alerts interruptive
6. use human factors principles three concepts that influence safety in ambulatory care - answer 1. role of pt and caregiver behaviors
7. role of provider-pt interactions
8. role of community and health system Medical Office Survey on Pt Safety Culture - answer designed to assess safety culture in amb care and data is available from AHRQ Pt Engagement - answer 1. ed pt about their illness and medications with pt demonstrating understanding "teach back"
9. empowering to act as a safety double check checklist - answer Algorithmic listing of actions to be performed for a given clinical procedure designed to ensure that no matter how often performed by a given clinician, no step will be forgotten reduce risk of slips consensus of required behaviors slips - answer failure of schematic (autopilot) behaviors lapses in concentration, distractions, or fatigue mistake - answer failures in attentional behavior lack of experience or insufficient training

Situational Awareness - answer the ability to access and track relevant to the task, comprehend the data, forecast what may happened based on the data, and formulate an appropriate plan in response situational awareness cannot be achieved without - answer clear and high-quality communication between all providers most common root cause of sentinel events - answer communication elements the affect communication - answer 1. rigid hierarchies

2. overtly disruptive and unprofessional behavior
3. nonverbal cues
4. interpersonal relations
5. group dynamics communication tools - answer read-back protocols SBAR teamwork training process for prescribing and adm meds - answer 1. order
6. Transcribing
7. dispensing
8. administration 90% errors occur at ordering (48%) or transcribing thus CPOE prevent CDSS - answer Clinical Decision Support System assist healthcare providers in the actual diagnosis and treatment of patients, analyze data from clinical information systems

avoids commission and omission errors unintended consequences of CPOE - answer 1. more or new work for clinicians

2. unfavorable workflow
3. never-ending system demands
4. persistence of paper orders
5. changes in communication patterns and practices
6. neg towards new technology
7. new types of errors
8. change in power structure, org culture , or professional roles High Reliability Organizations (HROs) - answer persistent mindfulness with in an organization cultivate resilience by relentlessly prioritizing safety over other performance pressures consistently minimize adverse events despite carrying out intrinsically complex and hazardous work safety is emergent vs. static commitment to safety at all levels HRO key features - answer 1. know high-risk nature of activities and determine to have consistent safe operations
9. blame-free
10. collaboration across ranks and disciplines
11. commitment of resources to address safety concerns Patient Safety Culture Surveys and Safety Attitudes Questionnaire - answer ask providers to rate the safety culture in their units and org as a whole poor perceived safety culture= increased error rates just culture - answer id and addressing systems issues that lead individual to engage in unsafe behaviors while maintain accountability human error (slip)

at risk behavior (short cuts) reckless behavior (ignoring required safety steps) Debriefing - answer dialogue to learn from defects and improve performance through goal discussion, reflection to incorporate improvement or discover opportunities in future performance simulation real-life emergency responses teamSTEPPS Components of debriefing - answer 1. setting the stage

2. description or reactions
3. analysis
4. application plus delta debriefing - answer 1. What went well?
5. What did not go well?
6. what can we do differently or what needs to change to improve care? debriefing framework - answer team evaluates if: had clear communication understanding of roles & responsibilities maintained sit awareness distributed workload cross-monitoring (asked and offered help prn) made, mitigated, or corrected errors detecting errors and safety hazards - answer goal to prospectively id hazards before pt harmed and analyzing events that have occurred to id and address underlying systems flaws

FMEA - answer Failure Mode and Effects Analysis

1. id all process steps "process mapping"
2. how each step can go wrong "failure modes"
3. impact of each error
4. likelihood of process failure
5. chance of detecting failure
6. impact of error SWIFT - answer structured what-if technique perceived safety problems can be detected through - answer safety culture surveys executive walk rounds techniques to retrospectively id safety hazards - answer 1. screen larger datasets for evidence of preventable adverse events that merit further investigation (trigger tools, patient safety indicators)
7. analyze individual cases of adverse events (RCA, mortality reviews, in-depth investigation) Patient Safety and Quality Improvement Act - answer Jan 2009 confidential and privilege protections for pt safety info when HCP work with Patient Safety Organizations hazard detection methods - answer voluntary error reports malpractice claims pt complaints executive walk rounds risk mgmt. database per Harvard Medical Practice Study, what % of errors were diagnostic - answer 17% 9% were undetected while pt was alive

heuristics - answer Mental shortcuts or "rules of thumb" that often lead to a solution (but not always) availability heuristic - answer dx of current pt biased by experience with past cases (crushing chest pain=MI) anchoring heuristic - answer relying on initial dx impression despite subsequent info to the contrary (BC with corynebacterium txed as contaminant when endocarditis) framing effects - answer dx decision making unduly biased by subtle cues and collateral information (addicted pt with abd pain tx for withdrawal but had bowel perf) blind obedience - answer undue reliance on test results or expert opinion (false neg rapid Strept test) prominent reason for malpractice claims - answer missed or delayed dx predisposing factors for dx error in ES and surgery - answer poor teamwork communication gold standard for diagnosis - answer autopsy goals is to have 25% inpt deaths autopsied prevent dx errors - answer 1. info technology 2.telephoen triage

3. teamwork & communication training
4. increased supervision of trainees mega-cognition - answer cognitive psychology reflect on own thinking with the hope to catch own misuse of heuristics before cause harm

components of disclosure that matter most to pts - answer 1. disclosure of all harmful errors

2. explanation why occurred
3. how error's effects will be minimized
4. steps taken to proven recurrences Full Disclosure Principle - answer disclose all circumstances and events, acknowledgement of responsibility, and apology fewer malpractice lawsuits and lower litigation cost CANDOR - answer Communication and Optimal Resolution used with disclosure of events % who reported witnessing physicians engage in disruptive behavior vs. nurses - answer 77% 65% physician disruptive and disrespectful behavior impact on nursing - answer dissatisfaction and likelihood of leaving nursing profession adverse events in OR % of healthcare professionals at any level engage in disruptive behavior - answer 2-4% disruptive behavior - answer disrespect for others interpersonal interaction that impedes the delivery of pt care subverts the org ability to develop a culture of safety (impacts teamwork and blame-free environment) unprofessional behavior in medical school is linked to subsequent disciplinary action by licensing board founder of patient safety movement - answer Dr. Lucian Leape prevent disruptive behavior - answer code of conduct defines and managing behaviors

leadership in ensuring culture of safety prevent behavior Bell Commission - answer 1987 mandating residents at New Your hospitals should work no more than 80 hours per week and no more than 24 consecutive hours due to Libby Zion's death due to med prescribing error Accreditation Council for Graduate Medical Education rules for work hours in 2003 - answer 1. no more than 80 hours per week

2. no more than 24 consecutive hours on duty
3. not be on call more than every 3rd night
4. must have 1 day off per week 2003 work hours regs impact on pt safety - answer no clear effect on pt safety or clinical outcomes may be due to the number of pt handoffs burnout and fatigue are still common Accreditation Council for Graduate Medical Education rules for work hours in 2017 - answer based on Flexibility in Duty Hours Requirements for Surgical Trainees (FIRST) same other than no 16 hour shift limit for first-year residents problems with EHR - answer 1.poor info display
5. complicated screen sequences and navigation
6. mismatch between user workflow safety hazards with data entry errors can be created by - answer 1. use of copy-forward or copy and paste
7. electronic signatures
8. lack of clarity in sources and date of information presented
9. alert fatigue

5. usability problems
6. altered workflow
7. altered communication Med errors not impacted by EHR - answer 1. wrong pt (bar coding decreases error)
8. wrong med at time of selection
9. wrong time SAFER guides - answer assessment checklists and structure for team to assess and improve their systems
10. high-priority practices
11. org responsibilities
12. contingency planning
13. system configuration
14. system interfaces
15. pt identification 7 CPOE with decision support
16. test result reporting and f/u
17. clinician communication suitability safety risk for EHR - answer 1. lack support of workflow
18. lack data coding, std, and structure
19. lack duplicate record detection
20. inaccurate, incomplete, or outdated decision support rules
21. bugs in software
22. content import features usability safety risk for EHR - answer 1. default values
23. problematic alerts
24. simultaneous task performance

4. inadequate info displays
5. unclear current state of user actio9ns in order processing
6. difficult interfaces
7. error-prone intervaces Human Factors Engineering - answer interaction between workers, the equipment, and their environment takes into account human strengths and limitations in the design of interactive systems HFE accesses - answer 1. physical demand
8. skill demands
9. mental workload
10. team dynamics
11. aspects of work environment
12. device design goal is to compete the task optimally usability testing - answer test in real-world conditions in order to id potential problems and unintended consequences of new technology will id workarounds forcing functions - answer prevents unintended or undesirable action from being performed or allows it performance only if another specific action is performed first (shift into reverse unless brake is pushed) does not always involve device design (removing potassium from med rooms) standardization - answer standardizing equipment and processes whenever possible to increase reliability, improve info flow, and minimize cross-training needs (checklists) resiliency efforts - answer attention to detection and mitigation before events occur

dynamic aspects of risk mgmt. to anticipate and adapt to changing conditions and recover from system anomalies HRO characteristic way of thinking - answer 1. preoccupation with failure

2. reluctance to simplify explanations for operations, successes, and failures
3. sensitivity to operations (situational awareness)
4. deference to frontline expertise
5. commitment to resilience Health literacy - answer individual's ability to find, process, and comprehend the basic health info necessary to act on medical instructions and make decisions about one's health Institute of Medicine definition of health literacy - answer function of systems within and beyond health care, and it involves interaction between the individual patient and health care system, as well as other social, cultural, and ed factors 2003 health literacy results - answer over a third had basic or below basic levels 53% had intermediate level 12% proficient why is health literacy not static - answer vary with mental or emotional state, illness, and life stressors individual skills complexity of info and tasks universal precautions for health literacy - answer 1. create shame-free environment
6. simplifying info (3 to 5 pts, 4-6th grade level)
7. listen carefully
8. confirm comprehension (teach back or show me)
9. improving support for navigation healthcare contexts (signage, forms, apps)
10. support in health mgmt efforts

CUSP - answer comprehensive unit-based safety program combines culture of safety, teamwork, and communications together with checklists that incorporate evidence-based measure to prevent HAI after how many hours does the drive for sleep become increasingly powerful - answer 12 to 16 hours fatigue - answer latent hazard and unsafe condition which leads to increased medical errors prefrontal cortex functions - answer memory and tracking capacity sensitive to sleep deprivation cumulative deficits related to sleep deprivations - answer dynamic, naturalistic decision-making executive function mode heightened irritability impaired communication and coordination cognitive performance less sensitive to sleep deprivation - answer complex tasks that are rule based & interesting require critical reasoning in logical well-practiced tasks mitigate the impact of extended work hours - answer conducting a risk assessment robust handoff practices involving staff design of work schedules fatigue mgmt plan with strategic use of caffeine and planned naps educate about sleep hygiene adequate environment for sleep breaks

falls rates - answer 3-5 per 1000 bed-days up to 1 million hospitalized pt fall each year 1.6 million NH residents each year 10% of Medicare SNC resident experience a significate injury with a fall falls occur in elderly with - answer 1. delirium

2. psychoactive meds (benzodiazepines)
3. baseline difficulties with strength, mobility, or balance Considerations in fall prevention program - answer 1. individualized
4. combine environmental measures (nonslip floors, within line sight)
5. clinical interventions (minimize deliriogenic meds)
6. care process interventions (std risk assessment tool)
7. cultural interventions (multidisciplinary)
8. tech/logistical interventions (lower bed) 2011 components of fall prevention interventions - answer 1. multidisciplinary
9. staff and pt ed
10. individualized POC
11. safe footware
12. focus on prevent, detect, and tx delirium
13. culprit meds
14. continence mgmt
15. device, mobility aids, and exercise
16. post fall review falls reportable to TJC - answer falls with injury are serious reportable event and a "never event" by CMS failure to rescue - answer not able to rapidly id and tx complications when they occur

inability to prevent death after the development of a complication reflect resources and preparedness of system how can a hospital have a low complication rate but high failure to rescue rate or vise versa - answer higher complications have more experience recognizing and responding to complications Needleman and Buerhaus - answer developed a measure o failure to rescue derived from adm data, used outcomes sensitive to nursing care, and integrated exclusion rules aimed to eliminate cases whicht he complication was POD "failure to rescue-nursing" death rate among surgical inpatients with serious txable conditions - answer 13.9% national rate associated with higher failure to rescue rates - answer 1. hospital volume

2. communication failures
3. lower nurse staffing The single greatest impediment to error prevention in the medical industry - answer we punish people for making mistakes individual performance rates - answer 3% physicians accounted for 49% of pt complaints 1% of physicians accounted for 32% of all malpractice complaints technically proficient but can provide unsafe care including - answer 1. poor communication skills
4. lack professionalism
5. medical or mental health conditions safe, high-quality care - answer well designed systems of care that are supported by individuals with a full range of competencies

% of physicians who develop a substance use disorder - answer 10-12% 2015 Annual Perspective on balance systems approach with accountability - answer just culture at risk vs. reckless improve performance - answer simulation individualized coaching CME mandate to report suspected impaired or unable to perform pt care duties leadership roles - answer 1. prioritizing safety

2. est culture of safety
3. responding to pt or staff concerns
4. supporting efforts to improve safety
5. monitor progress Board of Directors Responsibilities - answer 1. formatting mission & key goals
6. ensuring financial viability
7. monitoring and eval performance of high-level executives
8. meets the needs of the community it serves
9. ensuring quality and safety of care discontinuity creates - answer opportunities for error when clinical information in not accurately transferred between providers "kids playing telephone" "handoffs" - answer transferring responsibility for a patient from one caregiver to another with the goal of providing timely, accurate information about a patient's plan of care, treatment, current condition and anticipated changes "signout" - answer act of transmitting information about a patient

leading cause of preventable error in ED physicians and trainees - answer communication failures I-PASS - answer gold std for standardized handoff bundle

• illness severity
• pt summary
• action list
• situational awareness and contingency plans
• synthesis by receiver (ask questions and confirm POC) TJC handoff process - answer 1. interactive communications

2. up to date and accurate info
3. limited interruptions
4. process for verification
5. opportunity to review any relevant hx data Office of the Inspector General study on SNF resident that required hospitalization each year - answer 25% % of Medicare beneficiaries that are d/c to some form of LTC facilities after hospital stay - answer 40% % of Medicare beneficiaries in SNF experience an adverse event during their stay and how many were preventable - answer 22% half 1999 institute of Medicine Report - answer "To err is human: building a safer health system " toll of medical errors at the national level - 98,000 deaths every year due to preventable harm no single validated method for measuring eh overall safety of care

Donabedian Triad - answer quality is viewed :

1. structure,
2. process,
3. outcome measurement is sued to - answer 1. eval effectiveness of intervention
4. id new or emerging safety threats
5. compare safety across setting
6. determine if safety is improving methods of measuring pt safety - answer 1. retrospective chart review - gold std
7. voluntary error reporting
8. automated surveillance
9. adm or claims data (AHRQ pt safety indicators)
10. pt reports 2015 Free From Harm by the National Patient Safety Foundation - answer call for creation of common set of safety metrics that reflect meaningful outcomes
11. est std set of process and outcome measures for use on a national basis
12. creating measures of pt safety for settings outside the hospital
13. improve the quality of safety reporting systems
14. develop ways of measuring safety in real time most common medication errors - answer 1. wrong time of administration
15. omission
16. wrong dose
17. wrong prep
18. wrong adm rate (IV meds)

most common self and caregiver medication errors - answer 1. low health literacy

2. poor provider-pt communication
3. absence of health literacy universal precautions prevention of medication errors - answer 1. barcoding
4. smart infusion pumps
5. single-use med packages
6. package design features
7. minimizing interruptions medication error - answer an error of commission or omission at any step between prescribing and receiving the med adverse drug event - answer harm experienced by a pt as a result of exposure to a medication does not necessarily indicate an error or poor quality care Preventable ADE - answer med error that reaches pt and causes any degree of harm about half are preventable potential ADE - answer med errors that do not cause any harm either because they are intercepted or luck (incorrect dose given but no clinical consequences) Ameliorable ADE - answer pt experienced harm from a med that, while not completely preventable, could have been mitigated (earlier detection could have reduced the level of harm the pt experienced) nonpreventable ADE - answer side effects event when prescribed and adm properly

strongest risk factor for ADE - answer polypharmacy Beers Criteria - answer Identifies High Risk Meds to Generate Wide List of Meds That Should be Avoided STOPP criteria - answer Screening Tool of Older Persons' potentially inappropriate Prescriptions more accurate predict ADE than Beers criteria most commonly meds that cause ADE - answer 1. antidiabetic agents

2. oral anticoagulants
3. antiplatelet agents
4. opioid pain meds medication reconciliation - answer screen for:
5. omitted needed meds
6. unnecessarily duplicate therapies
7. incorrect doses
8. incomplete list of all medications Med rec is done - answer 1. time of admt
9. time of transfer
10. time of discharge med rec alone does not - answer reduce readmissions or other ADE

• resource intensive
• disincentive from investing
• altered workflow
• inefficiencies and confusion
• conflict between med rec and other quality improvement priorities

nursing omission error - answer missed nursing care needed nursing care that is delayed, partially completed, or not completed at all structural factors contributing to missed nursing care - answer 1. labor resources

2. material resources
3. teamwork and communication nursing decision process is influenced by - answer 1. nurse's perceptions of team or group norms
4. judgment about the importance of various aspects of care relative to the conditions of multiple pts
5. nurse's values, attitudes, and beliefs
6. nurse's usual practice never events - answer Serious but preventable errors that should never occur

• unambiguous (id and measurable)
• serious (death or disability)
• preventable categories of serious reportable events - answer 1. surgical or procedural

2. product or device
3. pt protected events
4. care mgmt events
5. environmental events
6. radiologic events
7. criminal Sentinel Event - answer an unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof

2004 Standards for Nursing-Sensitive Care - answer markers of nursing care quality and system-related measures including:

• nsg skill mix
• nsg care hrs
• measures of quality of nursing practice env
• nursing turnover 1994 Error in Medicine - answer Dr. Lucian Leape highlighted the issue & presented a framework for error analysis and prevention preventable adverse event - answer those due to error or failure to apply an acceptable strategy for prevention 2001 Making Health Care Safer Report - answer AHRQ first effort to use evidence-based medicine principles to id practices to improve pt safety 2013 Making Health Care Safer II - answer AHRQ added to the evidence based behind pt safety interventions 2015 Free From Harm Report - answer National Patient Safety Foundation

1. leaders est and sustain a safety culture
2. centralized and coordinated oversight of pt safety
3. create a common set of safety metrics the reflect meaningful outcomes
4. increase funding for research in pt safety and implementation science
5. safety across the entire care continuum
6. support healthcare workforce
7. partner with pt and families
8. ensure technology is safe and optimized

patient-centered care - answer respectful of and responsive to individual pt preferences, needs, and values and ensure that pt values guide all clinical decisions Engagement of patients in safety - answer 1. enlisting pt in detecting adverse events

2. empowering pt to ensure safe care
3. emphasizing pt involvmetn as means of improving the culture of safety patient action errors - answer 1. pt behaviors
4. mental errors errors related to radiotherapy - answer 1. overexposure
5. wrong pt
6. wrong site
7. poor communication
8. wrong dosing or incorrect configuration of equipment
9. inadequate training
10. poor interoperability of systems diagnostic imaging prevention to limit radiation - answer 1. ed physicans on appropriate test utilization
11. std equipment
12. radiation dosage
13. use ultrasound or MRI instead Rapid Response Team - answer a team that is trained to intervene and assist caregivers before a patient's condition deteriorates to the point that a conventional code is required. RRT criteria - answer HR over 140 or less than 40 resp over 28 or less than 8 SBP greater than 180 or less than 90

o2 sat less than 90% with air acute mental status change output less than 50 cc over 4 hrs member has a concern RRT do not affect - answer in-hospital mortality % of adverse events within 3 wks of discharge - answer 20% 3/4 prevented or ameliorated ameliorated - answer to make better or more tolerable % of Medicare pt re-hospitalized within 30 days of d/c - answer 20% prevention of adverse events after d/c - answer 1. med reconciliation

2. structured d/c communication
3. pt education Care Transitions Trial and Project Red - answer reduction of readmissions and ED visits after d/c passive form of surveillance for safety - answer voluntary reporting for near misses or unsafe conditions active form of surveillance for safety - answer direct observation chart review using triggers effective event reporting system - answer 1. supportive env for reporting that protects privacy who report occurrences
4. reports from board range of personnel
5. timely summaries disseminated

4. mechanism to review and dev action plans MedMARx program - answer US voluntary medication error reporting two most commonly reported events - answer 1. medication errors
5. falls top perceived barriers to incident reporting for Dr. - answer 1. no feedback or incident f/u
6. form to long or lack of time
7. incident was trivial
8. ward was busy or forgot to report
9. unsure of who should complete Common Formats for reporting safety events - answer AHRQ std definitions and reporting formats active errors - answer occurring at the point of interface between humans and complex system latent errors - answer hidden problems within health care systems that contribute to adverse events factors that may lead to latent errors - answer 1. institutional or regulatory
10. organizational or mgmt
11. work env
12. team env
13. staffing
14. task related
15. pt characteristics why RCA fail to result in improvment - answer 1. overreliance on weak solutions (education)
16. failure to aggregate data across institutions,