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QUESTIONS AND 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 -