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?
Give this one a try later!
, 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
A known barrier to patient safety is staff not speaking up when they are concerned or
if they see safety violations. You would help foster a culture that supports speaking up
by:
Give this one a try later!
a. Putting up posters around the organization that reinforce speaking up as
a safety strategy
b. Using culture of safety data to assist low performing departments with
defining strategies for improvement
c. Using tends in event reporting to identify staff who don't speak up
d. Re-educating management on the use of Just Culture principles
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?
Give this one a try later!
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?
Give this one a try later!
, 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
A known barrier to patient safety is staff not speaking up when they are concerned or
if they see safety violations. You would help foster a culture that supports speaking up
by:
Give this one a try later!
a. Putting up posters around the organization that reinforce speaking up as
a safety strategy
b. Using culture of safety data to assist low performing departments with
defining strategies for improvement
c. Using tends in event reporting to identify staff who don't speak up
d. Re-educating management on the use of Just Culture principles
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?
Give this one a try later!
