And Answers
What factors increase risk of falling? History of falling
65 years or older
Reduced vision
Orthostatic hypotension
Lower-extremity weakness
Gait & balance
Urinary incontinence
Improper use of walking aids
Various medications
HIV, aids, and hepatitis B virus or transmitted how? Blood, and other select body fluids
What is adverse event? An event that results in unintended harm to the patient by an act of
commission/omission rather than disease or condition.
Commission: irresponsible act you do
Omission: act you choose not to do and affect someone else
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And Answers
What is a near miss? An error of commission/omission that could have harmed the
patient, but serious harm did not occur as a result of chance, prevention, mitigation.
What is a sentinel event? An unexpected occurrence involving death, serious physical or
psychological injury.
(Loss of limb/function, "sentinel" = immediate investigation)
What are diagnostic errors? The result of delay in diagnosis
Failure to employee indicated test
Use of outmoded test
Failure to act on results of test
What is a treatment error? Occurs in the performance of an operation.
(Procedure, test, administering treatment; dose/method of administering a drug; or an avoidable
delay in treatment or in responding to an abnormal test)
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What are preventative errors? Failures to provide prophylactic treatment and in adequate
monitoring/follow-up of treatment.
(Realizing somethings wrong and not correcting it)
What is an active error? Errors made by those who are providing care, responding to
patient's needs at "sharp end."
(Sharp end correlates with direct patient care, placement of error)
What is a latent error? More organizational, contextual, and diffuse in nature or design
related. Errors at the "blunt end"
(Blunt end correlates with Organized systems, placement of error)
What does "just culture" refer to? Seeks to find a balance between the need to learn from
mistakes and the need for disciplinary action against employees.
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(People are not punished for a flawed system. There are exceptions.)
What antecedents need to exist in order for safety to be a concept? Knowledge of risk
Professional accountability
Motivation to achieve safety
Effective system process
Collaboration
T/F: A pathogen is present, so no infection will occur. False
What has to happen in order for infection to occur? The chain of infection must stay intact
What is the chain of infection? 1. Etiologic agent (microorganisms, toxin)
2. Reservoir (survive, multiply, await transfer)
3. Portal of exit (blood, mucous membranes)
4. Mode of transmission (hand hygiene, equipment)