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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?