NUR 2206 Exam 1 Study Guide W/NUR 2207 Vocab –
Questions With Solutions
Safety Regulations, Guidelines, and Agencies Right Ans - Agency for
Healthcare Research and Quality (AHRQ)
-Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS)
Institute for Safe Medication Practices (ISMP)
Institute of Medicine (IOM)
-In 2016, name changed to National Academy of Sciences, Engineering, and
Medicine
Quality and Safety Education for Nurses (QSEN)
IOM Report (1999): To Err is Human Right Ans - 98,000 lives lost each year
from medical errors in hospitals in the US
Medical error = the failure of a planned action to be completed as intended, or
the use of a wrong plan to achieve an aim
Cost of medical errors
Connection between quality care and patient safety
Preventing death and injury from medical errors requires dramatic, system
wide changes
-preventing, recognizing, and mitigating harm from error
To Err is Human: Initiatives Right Ans - Creation of a National Center for
Patient Safety within the Agency for Healthcare Research and Quality (AHRQ)
Mandatory and Voluntary reporting systems
Role of consumers, professionals, and accreditation groups
Building a culture of society
,Quality and Safety in Nursing Education (QSEN) Right Ans - Provides
framework for nursing school curricula
6 Competencies
Knowledge, skills, and attitudes (KSAs) for each competency
6 Competencies Right Ans - Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
Science of Safety Right Ans - Minimize risk of harm to patients and
providers through both system effectiveness and individual performance
(QSEN)
Science of Safety
-Human error (predictable)
Human factors
-Refers to the study of human behavior, abilities, limitations, and other
characteristics as they affect the design and smooth operation of equipment,
systems, jobs, and work environment (AHRQ)
Adverse Event (AE) Right Ans - Injury caused by medical care
Adverse Drug Event (ADE) Right Ans - Adverse event involving medication
use
ie. giving a patient penicillin and they unexpectedly break out in hives
Sentinel Event Right Ans - Adverse event that causes death or serious harm
to the patient
Usually events that are not expected or anticipated
ie. Roberts falling while walking to bathroom and she breaks her hip
Medication Error Right Ans - Preventable event related to mistake in
prescribing, dispensing, and/or administering medications
,Root Cause Analysis Right Ans - Identifies problems that increase the
likelihood of errors
Structured process for identifying contributing factors underlying adverse
events
Identify underlying problems that increase the likelihood of errors while
avoiding focusing on mistakes by individuals
Reporting of Errors Right Ans - Aimed to learn!
Just-culture
Blame-free, non-punitive reporting systems aimed at decreasing errors and
improving quality care and patient safety
Unsafe Practices Right Ans - Work-arounds (AHRQ)
-a deviation from the unexpected pattern of work to achieve an end result by
bypassing safety features
-often the result of poorly designed processes or equipment
Dangerous abbreviations
Relying on memory
Strategies to Eliminate Errors and Unsafe Practices Right Ans -
Communication
-interprofessional communication (IPC)
-SBAR
Organizational error reporting systems
Rounding
Huddles - group meetings before/during shift
Strategies to Eliminate Errors and Unsafe Practices (cont.) Right Ans - Peer
checking
Checklists
, Mnemonics
60 second situational awareness (!!)
Patient ID using name and DOB
Safety enhancing technologies
-bar coding, computer provider order entry (CPOE), smart pumps, automatic
alarms/alerts
Rank Order of Error Reducing Strategies Right Ans - (Most to least
Effective)
Forcing functions and constraints
Automation and computerization
Standardization
Checklists and double check systems
Rules and policies
Education/information
"Be more careful" ---> not very effective!
Culture of Safety Right Ans - Commitment to safety that permeates all
levels of an organization from front-line personnel to executive management
(Institute for Healthcare Improvement)
Product of individual and group values, attitudes, perceptions, competencies,
and patterns of behavior that determine the commitment to, and style and
proficiency of, an organization's health and safety management
Purpose is prevention of errors and elimination of unsafe practices
Key Elements of a Culture of Safety Right Ans - leadership, environment,
communication
Leadership Right Ans - Commitment to safety
Non-punitive approach to error reporting
Staff education
Environment Right Ans - Nurse-patient ratios
BSN educated RNs
Teamwork
Questions With Solutions
Safety Regulations, Guidelines, and Agencies Right Ans - Agency for
Healthcare Research and Quality (AHRQ)
-Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS)
Institute for Safe Medication Practices (ISMP)
Institute of Medicine (IOM)
-In 2016, name changed to National Academy of Sciences, Engineering, and
Medicine
Quality and Safety Education for Nurses (QSEN)
IOM Report (1999): To Err is Human Right Ans - 98,000 lives lost each year
from medical errors in hospitals in the US
Medical error = the failure of a planned action to be completed as intended, or
the use of a wrong plan to achieve an aim
Cost of medical errors
Connection between quality care and patient safety
Preventing death and injury from medical errors requires dramatic, system
wide changes
-preventing, recognizing, and mitigating harm from error
To Err is Human: Initiatives Right Ans - Creation of a National Center for
Patient Safety within the Agency for Healthcare Research and Quality (AHRQ)
Mandatory and Voluntary reporting systems
Role of consumers, professionals, and accreditation groups
Building a culture of society
,Quality and Safety in Nursing Education (QSEN) Right Ans - Provides
framework for nursing school curricula
6 Competencies
Knowledge, skills, and attitudes (KSAs) for each competency
6 Competencies Right Ans - Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
Science of Safety Right Ans - Minimize risk of harm to patients and
providers through both system effectiveness and individual performance
(QSEN)
Science of Safety
-Human error (predictable)
Human factors
-Refers to the study of human behavior, abilities, limitations, and other
characteristics as they affect the design and smooth operation of equipment,
systems, jobs, and work environment (AHRQ)
Adverse Event (AE) Right Ans - Injury caused by medical care
Adverse Drug Event (ADE) Right Ans - Adverse event involving medication
use
ie. giving a patient penicillin and they unexpectedly break out in hives
Sentinel Event Right Ans - Adverse event that causes death or serious harm
to the patient
Usually events that are not expected or anticipated
ie. Roberts falling while walking to bathroom and she breaks her hip
Medication Error Right Ans - Preventable event related to mistake in
prescribing, dispensing, and/or administering medications
,Root Cause Analysis Right Ans - Identifies problems that increase the
likelihood of errors
Structured process for identifying contributing factors underlying adverse
events
Identify underlying problems that increase the likelihood of errors while
avoiding focusing on mistakes by individuals
Reporting of Errors Right Ans - Aimed to learn!
Just-culture
Blame-free, non-punitive reporting systems aimed at decreasing errors and
improving quality care and patient safety
Unsafe Practices Right Ans - Work-arounds (AHRQ)
-a deviation from the unexpected pattern of work to achieve an end result by
bypassing safety features
-often the result of poorly designed processes or equipment
Dangerous abbreviations
Relying on memory
Strategies to Eliminate Errors and Unsafe Practices Right Ans -
Communication
-interprofessional communication (IPC)
-SBAR
Organizational error reporting systems
Rounding
Huddles - group meetings before/during shift
Strategies to Eliminate Errors and Unsafe Practices (cont.) Right Ans - Peer
checking
Checklists
, Mnemonics
60 second situational awareness (!!)
Patient ID using name and DOB
Safety enhancing technologies
-bar coding, computer provider order entry (CPOE), smart pumps, automatic
alarms/alerts
Rank Order of Error Reducing Strategies Right Ans - (Most to least
Effective)
Forcing functions and constraints
Automation and computerization
Standardization
Checklists and double check systems
Rules and policies
Education/information
"Be more careful" ---> not very effective!
Culture of Safety Right Ans - Commitment to safety that permeates all
levels of an organization from front-line personnel to executive management
(Institute for Healthcare Improvement)
Product of individual and group values, attitudes, perceptions, competencies,
and patterns of behavior that determine the commitment to, and style and
proficiency of, an organization's health and safety management
Purpose is prevention of errors and elimination of unsafe practices
Key Elements of a Culture of Safety Right Ans - leadership, environment,
communication
Leadership Right Ans - Commitment to safety
Non-punitive approach to error reporting
Staff education
Environment Right Ans - Nurse-patient ratios
BSN educated RNs
Teamwork
