ATI Leadership: Patient Safety & Error Prevention (Nursing
2026/2027) Questions |Answers |Rationales
1. A nurse manager is implementing a root cause analysis (RCA) after a
medication error. What is the primary purpose of an RCA?
A. To identify which staff member is responsible for the error
B. To document the error in the patient’s permanent medical record
C. To provide a basis for disciplinary action against the nurse
D. To discover the underlying systemic factors that contributed to the error
Answer: D
Rationale: The primary goal of a Root Cause Analysis (RCA) is to identify system-level
vulnerabilities rather than individual blame, focusing on preventing future occurrences.
2. Which of the following events is classified as a ‘Sentinel Event’ by The Joint
Commission?
A. A patient falling without sustaining any injury
B. Surgery performed on the wrong body part
C. A medication error that is caught before administration
D. A patient complaining about the quality of hospital food
Answer: B
Rationale: A sentinel event is an unexpected occurrence involving death or serious
physical or psychological injury, such as wrong-site surgery.
,3. A nurse is completing an incident report after a patient fall. Which action
should the nurse take regarding the report?
A. Place the incident report in the patient’s medical record
B. Note in the medical record that an incident report was filed
C. Submit the report to the risk management department according to facility policy
D. Include the incident report number in the nursing progress notes
Answer: C
Rationale: Incident reports are internal risk management documents and should never be
placed in or mentioned within the patient’s medical record.
4. When using the SBAR communication tool, which information belongs in the
‘Assessment’ section?
A. The patient’s name and room number
B. A summary of the patient’s current vital signs and clinical status
C. The patient’s medical history and allergies
D. A request for a specific intervention or change in treatment
Answer: B
Rationale: The Assessment portion of SBAR focuses on the nurse’s clinical findings and the
current status of the patient.
5. A nurse is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which
task is appropriate for delegation?
A. Evaluating a patient’s response to pain medication
B. Providing discharge instructions to a stable patient
C. Measuring and recording intake and output
D. Performing an initial admission assessment
Answer: C
Rationale: UAPs can perform routine tasks such as I&O. Assessment, teaching, and clinical
judgment cannot be delegated.
, 6. In the Plan-Do-Study-Act (PDSA) cycle of Quality Improvement, what occurs
during the ‘Study’ phase?
A. The team implements the planned change on a small scale
B. The team analyzes the data collected to see if the change worked
C. The team identifies the problem and plans a solution
D. The team integrates the change into permanent practice
Answer: B
Rationale: The ‘Study’ phase involves analyzing results and comparing data against the
predictions made during the ‘Plan’ phase.
7. A nurse is prioritizing care for four patients. Which patient should the nurse
see first?
A. A patient with a fracture requesting pain medication
B. A patient who is 1 day postoperative and has not yet voided
C. A patient with heart failure reporting new onset of shortness of breath
D. A patient who needs a dressing change before discharge
Answer: C
Rationale: Using the ABC (Airway, Breathing, Circulation) framework, the patient with
new shortness of breath is the highest priority.
8. Which of the following is a ‘Just Culture’ approach to error reporting?
A. Focusing on system failures while still holding individuals accountable for reckless behavior
B. Creating a system where errors are ignored to maintain morale
C. Automatically terminating employees who make medication errors
D. Reporting all errors directly to the state board of nursing immediately
Answer: A
Rationale: Just Culture balances a non-punitive environment for human error with
accountability for intentional or reckless actions.
2026/2027) Questions |Answers |Rationales
1. A nurse manager is implementing a root cause analysis (RCA) after a
medication error. What is the primary purpose of an RCA?
A. To identify which staff member is responsible for the error
B. To document the error in the patient’s permanent medical record
C. To provide a basis for disciplinary action against the nurse
D. To discover the underlying systemic factors that contributed to the error
Answer: D
Rationale: The primary goal of a Root Cause Analysis (RCA) is to identify system-level
vulnerabilities rather than individual blame, focusing on preventing future occurrences.
2. Which of the following events is classified as a ‘Sentinel Event’ by The Joint
Commission?
A. A patient falling without sustaining any injury
B. Surgery performed on the wrong body part
C. A medication error that is caught before administration
D. A patient complaining about the quality of hospital food
Answer: B
Rationale: A sentinel event is an unexpected occurrence involving death or serious
physical or psychological injury, such as wrong-site surgery.
,3. A nurse is completing an incident report after a patient fall. Which action
should the nurse take regarding the report?
A. Place the incident report in the patient’s medical record
B. Note in the medical record that an incident report was filed
C. Submit the report to the risk management department according to facility policy
D. Include the incident report number in the nursing progress notes
Answer: C
Rationale: Incident reports are internal risk management documents and should never be
placed in or mentioned within the patient’s medical record.
4. When using the SBAR communication tool, which information belongs in the
‘Assessment’ section?
A. The patient’s name and room number
B. A summary of the patient’s current vital signs and clinical status
C. The patient’s medical history and allergies
D. A request for a specific intervention or change in treatment
Answer: B
Rationale: The Assessment portion of SBAR focuses on the nurse’s clinical findings and the
current status of the patient.
5. A nurse is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which
task is appropriate for delegation?
A. Evaluating a patient’s response to pain medication
B. Providing discharge instructions to a stable patient
C. Measuring and recording intake and output
D. Performing an initial admission assessment
Answer: C
Rationale: UAPs can perform routine tasks such as I&O. Assessment, teaching, and clinical
judgment cannot be delegated.
, 6. In the Plan-Do-Study-Act (PDSA) cycle of Quality Improvement, what occurs
during the ‘Study’ phase?
A. The team implements the planned change on a small scale
B. The team analyzes the data collected to see if the change worked
C. The team identifies the problem and plans a solution
D. The team integrates the change into permanent practice
Answer: B
Rationale: The ‘Study’ phase involves analyzing results and comparing data against the
predictions made during the ‘Plan’ phase.
7. A nurse is prioritizing care for four patients. Which patient should the nurse
see first?
A. A patient with a fracture requesting pain medication
B. A patient who is 1 day postoperative and has not yet voided
C. A patient with heart failure reporting new onset of shortness of breath
D. A patient who needs a dressing change before discharge
Answer: C
Rationale: Using the ABC (Airway, Breathing, Circulation) framework, the patient with
new shortness of breath is the highest priority.
8. Which of the following is a ‘Just Culture’ approach to error reporting?
A. Focusing on system failures while still holding individuals accountable for reckless behavior
B. Creating a system where errors are ignored to maintain morale
C. Automatically terminating employees who make medication errors
D. Reporting all errors directly to the state board of nursing immediately
Answer: A
Rationale: Just Culture balances a non-punitive environment for human error with
accountability for intentional or reckless actions.
