AWHONN POEP MODULE 15
Swiss\cheese\is\often\used\as\the\paradigm\for\explaining\medical\error.\In\this\model,\the\
holes\in\the\cheese\represent\-\ans✔latent\weaknesses.
Which\of\the\following\has\been\noted\among\the\top\three\root\causes\of\sentinel\events\
for\over\10\years?\-\ans✔Communication
You\are\assigned\to\a\patient\who\is\at\38\weeks\and\6\days\gestation.\She\is\being\
admitted\for\an\elective\induction\of\labor\because\her\husband\is\going\on\an\extended\
business\trip\in\2\days\and\he\wants\to\be\present\for\the\delivery.\The\hospital\has\no\
policy\regarding\elective\induction,\but\you\know\that\the\AWHONN\"Go\the\Full\40"\
campaign\doesn't\support\early\elective\induction.\You\approach\the\physician\with\your\
concerns.\He\responds\that\he's\been\doing\this\for\30\years\and\has\never\had\a\bad\
outcome\from\an\elective\induction\at\this\gestation.\This\scenario\is\an\example\of\-\
ans✔normalization\of\deviance.
A\patient\safety\event,\unrelated\to\the\natural\course\of\the\underlying\illness,\that\
reaches\a\patient\and\results\in\death,\permanent\harm,\or\severe\temporary\harm\is\an\
example\of\-\ans✔a\sentinel\event.
Which\organization\developed\a\framework\for\the\pursuit\of\improving\health\and\
healthcare\worldwide,\known\as\the\Triple\Aim?\-\ans✔Institute\for\Healthcare\
Improvement\(IHI)
Which\of\the\following\is\not\a\component\of\the\risk\reduction\strategy\known\as\closed\
loop\communication?\-\ans✔Is\only\used\in\emergency\patient\care\situations.
Authoritative\statements\that\describe\a\competent\level\of\clinical\nursing\practice\
through\assessment,\diagnosis,\outcome\identification,\planning,\implementation,\and\
evaluation\are\defined\as\-\ans✔Standards\of\Care.
The\Institute\for\Safe\Medication\Practices\has\identified\which\two\medications\as\high\
risk\in\the\perinatal\setting?\-\ans✔Magnesium\sulfate\and\oxytocin
You\are\a\nurse\on\the\mother/baby\unit\caring\for\a\woman\who\is\12\hours\postpartum\
from\a\low\forceps-assisted\delivery\with\midline\episiotomy.\The\woman\has\severe\
rectal\pain\and\reports\inability\to\urinate.\You\suspect\a\vaginal\hematoma\and\call\her\
Swiss\cheese\is\often\used\as\the\paradigm\for\explaining\medical\error.\In\this\model,\the\
holes\in\the\cheese\represent\-\ans✔latent\weaknesses.
Which\of\the\following\has\been\noted\among\the\top\three\root\causes\of\sentinel\events\
for\over\10\years?\-\ans✔Communication
You\are\assigned\to\a\patient\who\is\at\38\weeks\and\6\days\gestation.\She\is\being\
admitted\for\an\elective\induction\of\labor\because\her\husband\is\going\on\an\extended\
business\trip\in\2\days\and\he\wants\to\be\present\for\the\delivery.\The\hospital\has\no\
policy\regarding\elective\induction,\but\you\know\that\the\AWHONN\"Go\the\Full\40"\
campaign\doesn't\support\early\elective\induction.\You\approach\the\physician\with\your\
concerns.\He\responds\that\he's\been\doing\this\for\30\years\and\has\never\had\a\bad\
outcome\from\an\elective\induction\at\this\gestation.\This\scenario\is\an\example\of\-\
ans✔normalization\of\deviance.
A\patient\safety\event,\unrelated\to\the\natural\course\of\the\underlying\illness,\that\
reaches\a\patient\and\results\in\death,\permanent\harm,\or\severe\temporary\harm\is\an\
example\of\-\ans✔a\sentinel\event.
Which\organization\developed\a\framework\for\the\pursuit\of\improving\health\and\
healthcare\worldwide,\known\as\the\Triple\Aim?\-\ans✔Institute\for\Healthcare\
Improvement\(IHI)
Which\of\the\following\is\not\a\component\of\the\risk\reduction\strategy\known\as\closed\
loop\communication?\-\ans✔Is\only\used\in\emergency\patient\care\situations.
Authoritative\statements\that\describe\a\competent\level\of\clinical\nursing\practice\
through\assessment,\diagnosis,\outcome\identification,\planning,\implementation,\and\
evaluation\are\defined\as\-\ans✔Standards\of\Care.
The\Institute\for\Safe\Medication\Practices\has\identified\which\two\medications\as\high\
risk\in\the\perinatal\setting?\-\ans✔Magnesium\sulfate\and\oxytocin
You\are\a\nurse\on\the\mother/baby\unit\caring\for\a\woman\who\is\12\hours\postpartum\
from\a\low\forceps-assisted\delivery\with\midline\episiotomy.\The\woman\has\severe\
rectal\pain\and\reports\inability\to\urinate.\You\suspect\a\vaginal\hematoma\and\call\her\
