HCQM-Patient Safety UPDATED ACTUAL
Exam Questions and CORRECT Answers
First organization developed expressly to improve safety for patients. - CORRECT
ANSWER -Anesthesia Patient Safety Foundation - founded 1985.
Ellison Pierce - CORRECT ANSWER -Established the Committee on Patient Safety and
Risk Management in 1982; coined the term "patient safety", founded the Anesthesia Patient
Safety Foundation in 1985; delivered the Rovenstine Lecture in 1996.
1996's Rovenstine Lecture (40 Years behind the Mask: Safety Revisited) - CORRECT
ANSWER -Ellison Pierce described the beginning of anesthesiology's patient safety
movement
1982 20/20's The Deep Sleep: 6000 will Die or Suffer Brain Damage - CORRECT
ANSWER -Inspired Pierce's Rovenstine Lecture about patient safety
After attending a workshop by Deming, Berwick realized he was misguided because he had been
- CORRECT ANSWER -An inspector rather than a promoter of quality.
1988 Institute for Healthcare Improvement was founded by - CORRECT ANSWER -Don
Berwick, Paul Batalden, and Gene Nelson. The institute focuses on all aspects of quality, but
their discovery of a modern approach to quality helped transform the patient safety movement.
Harvard Medical Practice Study I and II - CORRECT ANSWER -Published in 1991 by the
New England Journal of Medicine it had the results from two large studies of adverse medical
events and provided the evidence that significant numbers of patients are harmed by medical
treatment and a framework for understanding the types of harm they experience.
Harvard Medical Practice Study I - CORRECT ANSWER -30,000 Medical records from
1984 non psych hospitals in NYS were screened for adverse events (injury caused by medical
management rather than underlying disease and prolonged the hospitalization or produced a
, disability at the time of discharge) and negligence (care falling below the standard expected of
physicians in their community).
Harvard Medical Practice Study II - CORRECT ANSWER -Classified the injuries
described in Study I and the management errors that were responsible.
Results of Harvard Medical Study II - CORRECT ANSWER -Adverse events occurred in
3.7% of hospitalizations and 27.6% of the events were due to negligence. 70.5% gave rise to
disability lasting less than six months, 2.6% caused permanently disabling injuries and 13.6% led
to death. Unfortunately it did not lead to immediate change.
Lucian Leape - CORRECT ANSWER -Co-author of the Harvard Medical Practice Study;
prominent leader in the patient safety movement; discovered how cognitive psychology and
human factors engineering were important aspects of improving patient safety
1994's Error in Medicine published in the Journal of the American Medical Association -
CORRECT ANSWER -Written by Lucian Leape it presented statistical evidence of the
occurrence of harm caused by medical errors along with lessons from other high risk industries
such as aviation.
The first mainstream article in healthcare literature arguing for a systems approach to safety. -
CORRECT ANSWER -Error in Medicine by Lucian Leape.
In Error in Medicine, Leape identified 3 categories of medical errors - CORRECT
ANSWER -Medication errors, missed diagnoses, operational errors such as delayed
treatment.
In Error in Medicine, Leape states the most fundamental change that must be made is -
CORRECT ANSWER -Cultural. Errors must be accepted as evidence of system flaws not
character flaws.
Exam Questions and CORRECT Answers
First organization developed expressly to improve safety for patients. - CORRECT
ANSWER -Anesthesia Patient Safety Foundation - founded 1985.
Ellison Pierce - CORRECT ANSWER -Established the Committee on Patient Safety and
Risk Management in 1982; coined the term "patient safety", founded the Anesthesia Patient
Safety Foundation in 1985; delivered the Rovenstine Lecture in 1996.
1996's Rovenstine Lecture (40 Years behind the Mask: Safety Revisited) - CORRECT
ANSWER -Ellison Pierce described the beginning of anesthesiology's patient safety
movement
1982 20/20's The Deep Sleep: 6000 will Die or Suffer Brain Damage - CORRECT
ANSWER -Inspired Pierce's Rovenstine Lecture about patient safety
After attending a workshop by Deming, Berwick realized he was misguided because he had been
- CORRECT ANSWER -An inspector rather than a promoter of quality.
1988 Institute for Healthcare Improvement was founded by - CORRECT ANSWER -Don
Berwick, Paul Batalden, and Gene Nelson. The institute focuses on all aspects of quality, but
their discovery of a modern approach to quality helped transform the patient safety movement.
Harvard Medical Practice Study I and II - CORRECT ANSWER -Published in 1991 by the
New England Journal of Medicine it had the results from two large studies of adverse medical
events and provided the evidence that significant numbers of patients are harmed by medical
treatment and a framework for understanding the types of harm they experience.
Harvard Medical Practice Study I - CORRECT ANSWER -30,000 Medical records from
1984 non psych hospitals in NYS were screened for adverse events (injury caused by medical
management rather than underlying disease and prolonged the hospitalization or produced a
, disability at the time of discharge) and negligence (care falling below the standard expected of
physicians in their community).
Harvard Medical Practice Study II - CORRECT ANSWER -Classified the injuries
described in Study I and the management errors that were responsible.
Results of Harvard Medical Study II - CORRECT ANSWER -Adverse events occurred in
3.7% of hospitalizations and 27.6% of the events were due to negligence. 70.5% gave rise to
disability lasting less than six months, 2.6% caused permanently disabling injuries and 13.6% led
to death. Unfortunately it did not lead to immediate change.
Lucian Leape - CORRECT ANSWER -Co-author of the Harvard Medical Practice Study;
prominent leader in the patient safety movement; discovered how cognitive psychology and
human factors engineering were important aspects of improving patient safety
1994's Error in Medicine published in the Journal of the American Medical Association -
CORRECT ANSWER -Written by Lucian Leape it presented statistical evidence of the
occurrence of harm caused by medical errors along with lessons from other high risk industries
such as aviation.
The first mainstream article in healthcare literature arguing for a systems approach to safety. -
CORRECT ANSWER -Error in Medicine by Lucian Leape.
In Error in Medicine, Leape identified 3 categories of medical errors - CORRECT
ANSWER -Medication errors, missed diagnoses, operational errors such as delayed
treatment.
In Error in Medicine, Leape states the most fundamental change that must be made is -
CORRECT ANSWER -Cultural. Errors must be accepted as evidence of system flaws not
character flaws.
