CPPS Review Course QUESTIONS AND ANSWERS ALL CORRECT

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