answers
You are educating clinical managers in your healthcare facility on how to identify
appropriate events for conducting a Root Cause Analysis. Which event provides the
best opportunity for an RCA? - ANSWER-a. A post-op 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. There have been 3 occurrences of depressed respirations in the same department in
the last 4 months related to sedation
The answer is C. The biopsy samples from a colonoscopy are never received by
pathology after the procedure - ANSWER-
The instrument count is incorrect at the conclusion of a surgical procedure. The hospital
policy does not stipulate that the surgeon remain on the premises until an x-ray is
obtained. The surgeon leaves the hospital to catch a flight. The x-ray reveals a retained
instrument. Another surgeon is contacted to remove the retained instrument. What
should leadership do next? - ANSWER-a. Create a process map of how instruments are
managed during surgery looking for latent flaws
b. Revise the hospital policy to make it clear that surgeons must stay in the OR until
instrument count issues are resolved
c. Counsel the surgeon about customary clinical standards for a surgeon using
appropriate accountability system
d. Reeducate the OR nursing staff on keeping track of instruments on the sterile field
,The answer is C. Counsel the surgeon about customary clinical standards for a surgeon
using appropriate accountability system - ANSWER-
A nurse on a medical-surgical unit does not comply with barcode medication
administration (BCMA) while caring for one of her patients. What should her supervisor
do? - ANSWER-a. Ask staff if there are adequate scanners to meet their needs
b. Counsel the nurse on the importance of following policy
c. Request that the pharmacy run a report of BCMA compliance rates of the unit
d. Ask the nurse what was occurring at the time, and why she chose to bypass the
policy
The answer is D. Ask the nurse what was occurring at the time, and why she chose to
bypass the policy - ANSWER-
The Board of Hospital A wants to know how Hospital A's safety performance in central
line associated blood stream infection (CLABSI) compares to that of other hospitals in
their region. Which data display would best inform them for that decision? - ANSWER-a.
Control charts of overall infection rate by quarter for the past two years for each hospital
in the region
b. A table indicating the CLABSI infection rates of all hospitals in the region relative to
the National Healthcare Safety Network benchmark for CLABSI infections for the past 2
years
c. A written report summarizing the current CLABSI prevention protocols of each
hospital in the region
d. A table showing the number of CLABSI infections in each hospital in the region by
quarter for the past 2 years
The answer is B. A table indicating the CLABSI infection rates of all hospitals in the
region relative to the National Healthcare Safety Network benchmark for CLABSI
infections for the past 2 years - ANSWER-
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 for next steps. What next steps would you take to identify a replacement
,system? - ANSWER-a. Ask information systems to either fix the old one or build a new
one
b. Identify key stakeholders and perform a gap analysis of current state to ideal state
c. Poll colleagues and purchase what they use
d. Purchase the lease expensive software and grow with it
The answer is B. Identify key stakeholders and perform a gap analysis of current state
to ideal state - ANSWER-
Your organization is preparing to change to a new electronic health record. Many
departments have been involved with the planning of this huge effort. What would you
suggest as part of the preparation strategy? - ANSWER-a. Conduct a root cause
analysis
b. Conduct a failure modes and effects analysis
c. Offer a "plan, do, study, act" session
d. Offer to do a claims analysis for any related errors
The answer is b. Conduct a failure modes and effects analysis - ANSWER-
A new cath lab is under construction in our hospital, and the medical director contacts
you to express concerns related to the transport of patients from the cath lab to the ICU.
You agree to assist in the design of an FMEA. Components of the FMEA will include: -
ANSWER-a. Assembling a multidisplinary team whose members will brainstorm
potential failures
b. Conducting the 5 "whys" to figure out what could go wrong
c. Listing potential root causes of adverse events in the current cath lab
d. Asking the medical director to participate in leadership rounds in the current cath lab
to identify potential safety risks
The answer is A. Assembling a multidisplinary team whose members will brainstorm
potential failures - ANSWER-
, A new medication administrative safety process was implemented in a hospital. A team
convened to perform a failure mode effects analysis and calculate a risk priority number
(RPN). After a targeted medication safety program on the new process was delivered to
nurses, the same team convened to perform another FMEA. The team would be happy
to see: - ANSWER-a. The detectability increased and RPNs were lower
b. The detectability decreased and RPNs were lower
c. The frequency numbers decreased and RPNs were higher
d. The frequency numbers increased and RPNs were lower
The answer is b. (I think) The detectability decreased and RPNs were lower -
ANSWER-
Sharing lessons learned from RCA's does what? - ANSWER-a. exposes the fallibility of
the involved clinician(s)
b. Allows others to introduce work arounds to avoid the same situation
c. Allows co-workers to learn the rationale for why an event occurred and incorporate
new lessons learned into practice
d. Sharing these events allows for exposure from litigation perspective and should not
be encouraged
The answer is C. Allows co-workers to learn the rationale for why an event occurred and
incorporate new lessons learned into practice - ANSWER-
Which of the following descriptions best reflects principles of safe system design? -
ANSWER-a. Hospital A routinely reviews and updates policies and procedures every 2
years
b. Hospital B routinely studies close calls
c. Hospital C routinely provides trainings on the use of newly introduced medical
equipment
d. Hospital D routinely utilizes control charting to report safety performance