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Correct Answers 2025 v v v
A staff member discovered a medication with an incorrect label. The staff immediately notified the pha
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vrmacist and the correct label was sent prior to medication administration. Then, the staff completed an event
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report through the organization's reporting tool.
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Which of the following actions should the unit manager take in response to this event?
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A.) Document the incident in the employee's performance review. v v v v v v v
B.) Investigate system failures and recognize the employee for reporting a near-miss event. v v v v v v v v v v v
C.) Notify the director of pharmacy about the pharmacist's error. v v v v v v v v
D.) No action, since the incident did not cause patient harm. - CORRECT ANSWER -
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B.) Investigate system failures and recognize the employee for reporting a near-miss event. v v v v v v v v v v v
You are educating clinical managers in your health care facility on how to identify appropriate events f or
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conducting a root cause analysis (RCA). Which event provides the BEST opportunity for an RCA?
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A.) A post-operative patient removes his own IV, causing a skin tear from the tape.
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B.) A patient with no known allergies experiences an anaphylactic reaction to an antibiotic, requiring tr ansfer
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to ICU.
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C.) The biopsy samples from a colonoscopy are never received by pathology afterVthe procedure.
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D.) In the last four months, there have been three occurrences of depressed respirations related to sedat ion in
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the same department. - CORRECT ANSWERV-
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C.) The biopsy samples from a colonoscopy are never received by pathology after the procedure.
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A hospital is using the AHRQ Hospital Survey on Patient Safety Culture. There were 80 employees w
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ho responded. Responses to the survey item that states "we have patient safety problems in this unit" w ere as
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follows:
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Strongly Agree: 16 v v
Agree: 32 v
Neither Agree nor Disagree: 12 Disagree: v v v v v
17
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Strongly Disagree: 3 v v
A.) 75% v
B.) 60% v
C.) 25% v
D.) 20% - CORRECT ANSWERV- v v v
C.) 25%The AHRQ Hospital Survey on Patient Safety Culture User Guide scoring guidance says to us e
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the "Strongly Agree/Agree" response sum, or, for negatively worded items—such as this one—
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use the "Strongly Disagree/Disagree" sum.
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In this example, 17+3 gives us the response sum (i.e., 20), which we divide by total number of respon dents
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(i.e., 80): 20/80 = 25%.
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What is one example of a communication technique providers can use to improve communication with
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patients?
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A.) SBAR
,B.) Teach-back
C.) CUSP
D.) Two-Challenge Rule - CORRECT ANSWER -B.) Teach-back v v v v v v
The Impact of Organizational Change on Safety
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What are the three steps to managing patient safety through organizational change?
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A.) Monitor change, identify potential safety implications, and employ countermeasures to mitigate any
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anticipated risks
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B.) Employ countermeasures to mitigate any anticipated risks, monitor change v v v v v v v v
C.) Identify potential safety implications, employ countermeasures to mitigate any anticipated risks, an d
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monitor the change
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D.) None of the above - CORRECT ANSWERV- v v v v v v
C.) Identify potential safety implications, employ countermeasures to mitigate any anticipated risks, an d
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monitor the change
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What is the term which describes the belief that one will not be punished or humiliated for speaking u p
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with ideas, questions, concerns, or mistakes? - CORRECT ANSWER -Psychological safety
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A safety-
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supportive system of shared accountability in which: 1.) Healthcare institutions are accountable for safe
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systems design and for encouraging safe choices of clinicians and staff (clear expectations set the tone to
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create environment of mutual respect)
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2.) Clinicians and staff are accountable for the quality of their choices (i.e. striving to make the best po ssible
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choices as professionals) - CORRECT ANSWER -Just Culture
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At the conclusion of a surgical procedure at your hospital, the instrument count is incorrect. The hospit al
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vpolicy does not stipulate that the surgeon must remain on the premises until an x-
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ray is obtained to check for retained foreign objects. By the time the x-
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ray results come in to reveal that there is, in fact, a retained instrument, the original surgeon has left th e
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vhospital to catch a flight. Another surgeon is contacted to remove the retained instrument.
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How should leadership respond to this event?
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A.) Revise the hospital policy to make it clear that surgeons must stay in the operating room (OR) unti l
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instrument count issues are resolved.
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B.) Using an appropriate accountability system, counsel the surgeon about customary clinical standards
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.
C.) Re-educate the OR nursing staff on keeping trackVof instruments on the sterile field. v v v v v v v v v v v v
D.) Create a process map of how instruments are managed during surgery, looking f -
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CORRECT ANSWER -
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B.) Using an appropriate accountability system, counsel the surgeon about customary clinical standards
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.
This term reflects a group of individuals who understand the importance of self- and group- regulation. -
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CORRECT ANSWER -Professionalism
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The human resources department at your organization has asked your patient safety specialist for reco
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vmmendations on new policies to help support safety culture. Which recommendation sounds best? v v v v v v v v v v v v
A.) Sending human resources all event data so that they can record involvement in adverse events in p
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versonnel files v
B.) Including human resources in all root cause analyses so that they can provide guidance on recomm ended v v v v v v v v v v v v v v v v
training updates for staff
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, C.) Implementing routine use of a tool to determine which events are attributed to human error, at- risk v v v v v v v v v v v v v v v v
behavior, and reckless behavior
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D.) Implementing routine use of a tool to determine which events are attributed to human error, at- risk v v v v v v v v v v v v v v v v
behavior, and reckless behavior AND consulting with human resources on at-
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risk and reckless behavior cases - CORRECT ANSWER -
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D.) Implementing routine use of a tool to determine which events are attributed to human error, at- risk
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behavior, and reckless behavior AND consulting with human resources on at-
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risk and reckless behavior cases
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At the end of a long, exhausting shift, an experienced nurse administered the wrong medication by pic king up
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the wrong syringe. The wrong medication was an analgesic, and the patient didn't suffer any p roblems. After
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recalling that his colleague was fired last month over a medication error, he decides not to file an incident
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report.
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Safety culture would be improved if the hospital provided this employee with which of the following?
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A.) Situational awareness training v v
B.) Training on reporting v v
C.) Psychological safety v
D.) An electronic reporting system - CORRECT ANSWERV-C.) Psychological safety
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A staff nurse at your hospital fails to complete a double-check before administering a high-
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alert medication. She gives the medication to the incorrect patient, and the patient suffers an arrhythmi a.
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When applying James Reason's unsafe acts algorithm, what is a strategy to use prior to holding the nur se
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personally accountable?
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A.) Perform the substitution test with three other nurses. v v v v v v v
B.) Have the chief nursing officer interview with the nurse.v v v v v v v v
C.) Hold a root cause analysis. v v v v
D.) Ask other nurses if the staff nurse is trustworthy. - CORRECT ANSWER -
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A.) Perform the substitution test with three other nurses. v v v v v v v
To improve culture of safety survey results, which of the following should an organization do?
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A.) Acknowledge and celebrate high-performing areas in front of leadership. v v v v v v v v
B.) Perform root cause analysis on underperforming units to better understand theirVresults.
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C.) Examine high-performing units to identify and disseminate best practices. v v v v v v v v
D.) Offer coaching and apply Just Culture principles to leaders in lower performing areas. -
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CORRECT ANSWER -C.) Examine high-performing units to identify and disseminate best practices.
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In which of the following activities would a patient safety specialist engage to promote a culture of saf ety?
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A.) Instruct team members to act in a safe and respectful manner. v v v v v v v v v v
B.) Focus on a list of projects identified by senior stakeholders. v v v v v v v v v
C.) Review annual data on defects and successes. v v v v v v
D.) Apply best evidence with the goal of failure-free operation over time. - CORRECT ANSWERV-
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D.) Apply best evidence with the goal of failure-free operation over time.
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As your organization's patient safety officer, you are reviewing unit results on the AHRQ Culture of S afety
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Survey. You are speaking with the manager of a unit for which the unit percent positive score is 30
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percent for the following statement: "Staff in this unit work longer hours than is best for patient car e."
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Correct Answers 2025 v v v
A staff member discovered a medication with an incorrect label. The staff immediately notified the pha
v v v v v v v v v v v v v v v
vrmacist and the correct label was sent prior to medication administration. Then, the staff completed an event
v v v v v v v v v v v v v v v v
report through the organization's reporting tool.
v v v v v v
Which of the following actions should the unit manager take in response to this event?
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A.) Document the incident in the employee's performance review. v v v v v v v
B.) Investigate system failures and recognize the employee for reporting a near-miss event. v v v v v v v v v v v
C.) Notify the director of pharmacy about the pharmacist's error. v v v v v v v v
D.) No action, since the incident did not cause patient harm. - CORRECT ANSWER -
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B.) Investigate system failures and recognize the employee for reporting a near-miss event. v v v v v v v v v v v
You are educating clinical managers in your health care facility on how to identify appropriate events f or
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conducting a root cause analysis (RCA). Which event provides the BEST opportunity for an RCA?
v v v v v v v v v v v v v v v
A.) A post-operative patient removes his own IV, causing a skin tear from the tape.
v v v v v v v v v v v v v
B.) A patient with no known allergies experiences an anaphylactic reaction to an antibiotic, requiring tr ansfer
v v v v v v v v v v v v v v v
to ICU.
v v
C.) The biopsy samples from a colonoscopy are never received by pathology afterVthe procedure.
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D.) In the last four months, there have been three occurrences of depressed respirations related to sedat ion in
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the same department. - CORRECT ANSWERV-
v v v v v v
C.) The biopsy samples from a colonoscopy are never received by pathology after the procedure.
v v v v v v v v v v v v v
A hospital is using the AHRQ Hospital Survey on Patient Safety Culture. There were 80 employees w
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ho responded. Responses to the survey item that states "we have patient safety problems in this unit" w ere as
v v v v v v v v v v v v v v v v v v v v
follows:
v
Strongly Agree: 16 v v
Agree: 32 v
Neither Agree nor Disagree: 12 Disagree: v v v v v
17
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Strongly Disagree: 3 v v
A.) 75% v
B.) 60% v
C.) 25% v
D.) 20% - CORRECT ANSWERV- v v v
C.) 25%The AHRQ Hospital Survey on Patient Safety Culture User Guide scoring guidance says to us e
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the "Strongly Agree/Agree" response sum, or, for negatively worded items—such as this one—
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use the "Strongly Disagree/Disagree" sum.
v v v v
In this example, 17+3 gives us the response sum (i.e., 20), which we divide by total number of respon dents
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(i.e., 80): 20/80 = 25%.
v v v v v
What is one example of a communication technique providers can use to improve communication with
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patients?
v
A.) SBAR
,B.) Teach-back
C.) CUSP
D.) Two-Challenge Rule - CORRECT ANSWER -B.) Teach-back v v v v v v
The Impact of Organizational Change on Safety
v v v v v v
What are the three steps to managing patient safety through organizational change?
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A.) Monitor change, identify potential safety implications, and employ countermeasures to mitigate any
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anticipated risks
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B.) Employ countermeasures to mitigate any anticipated risks, monitor change v v v v v v v v
C.) Identify potential safety implications, employ countermeasures to mitigate any anticipated risks, an d
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monitor the change
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D.) None of the above - CORRECT ANSWERV- v v v v v v
C.) Identify potential safety implications, employ countermeasures to mitigate any anticipated risks, an d
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monitor the change
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What is the term which describes the belief that one will not be punished or humiliated for speaking u p
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with ideas, questions, concerns, or mistakes? - CORRECT ANSWER -Psychological safety
v v v v v v v v v v v
A safety-
v
supportive system of shared accountability in which: 1.) Healthcare institutions are accountable for safe
v v v v v v v v v v v v v
systems design and for encouraging safe choices of clinicians and staff (clear expectations set the tone to
v v v v v v v v v v v v v v v v v
create environment of mutual respect)
v v v v v
2.) Clinicians and staff are accountable for the quality of their choices (i.e. striving to make the best po ssible
v v v v v v v v v v v v v v v v v v v
choices as professionals) - CORRECT ANSWER -Just Culture
v v v v v v v v
At the conclusion of a surgical procedure at your hospital, the instrument count is incorrect. The hospit al
v v v v v v v v v v v v v v v v v
vpolicy does not stipulate that the surgeon must remain on the premises until an x-
v v v v v v v v v v v v v v
ray is obtained to check for retained foreign objects. By the time the x-
v v v v v v v v v v v v v
ray results come in to reveal that there is, in fact, a retained instrument, the original surgeon has left th e
v v v v v v v v v v v v v v v v v v v v
vhospital to catch a flight. Another surgeon is contacted to remove the retained instrument.
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How should leadership respond to this event?
v v v v v v
A.) Revise the hospital policy to make it clear that surgeons must stay in the operating room (OR) unti l
v v v v v v v v v v v v v v v v v v
instrument count issues are resolved.
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B.) Using an appropriate accountability system, counsel the surgeon about customary clinical standards
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.
C.) Re-educate the OR nursing staff on keeping trackVof instruments on the sterile field. v v v v v v v v v v v v
D.) Create a process map of how instruments are managed during surgery, looking f -
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CORRECT ANSWER -
v v v
B.) Using an appropriate accountability system, counsel the surgeon about customary clinical standards
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.
This term reflects a group of individuals who understand the importance of self- and group- regulation. -
v v v v v v v v v v v v v v v v
CORRECT ANSWER -Professionalism
v v v
The human resources department at your organization has asked your patient safety specialist for reco
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vmmendations on new policies to help support safety culture. Which recommendation sounds best? v v v v v v v v v v v v
A.) Sending human resources all event data so that they can record involvement in adverse events in p
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versonnel files v
B.) Including human resources in all root cause analyses so that they can provide guidance on recomm ended v v v v v v v v v v v v v v v v
training updates for staff
v v v v
, C.) Implementing routine use of a tool to determine which events are attributed to human error, at- risk v v v v v v v v v v v v v v v v
behavior, and reckless behavior
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D.) Implementing routine use of a tool to determine which events are attributed to human error, at- risk v v v v v v v v v v v v v v v v
behavior, and reckless behavior AND consulting with human resources on at-
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risk and reckless behavior cases - CORRECT ANSWER -
v v v v v v v v
D.) Implementing routine use of a tool to determine which events are attributed to human error, at- risk
v v v v v v v v v v v v v v v v v
behavior, and reckless behavior AND consulting with human resources on at-
v v v v v v v v v v v
risk and reckless behavior cases
v v v v
At the end of a long, exhausting shift, an experienced nurse administered the wrong medication by pic king up
v v v v v v v v v v v v v v v v v v
the wrong syringe. The wrong medication was an analgesic, and the patient didn't suffer any p roblems. After
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recalling that his colleague was fired last month over a medication error, he decides not to file an incident
v v v v v v v v v v v v v v v v v v v
report.
v
Safety culture would be improved if the hospital provided this employee with which of the following?
v v v v v v v v v v v v v v v
A.) Situational awareness training v v
B.) Training on reporting v v
C.) Psychological safety v
D.) An electronic reporting system - CORRECT ANSWERV-C.) Psychological safety
v v v v v v v v
A staff nurse at your hospital fails to complete a double-check before administering a high-
v v v v v v v v v v v v v v
alert medication. She gives the medication to the incorrect patient, and the patient suffers an arrhythmi a.
v v v v v v v v v v v v v v v v
When applying James Reason's unsafe acts algorithm, what is a strategy to use prior to holding the nur se
v v v v v v v v v v v v v v v v v v
personally accountable?
v v
A.) Perform the substitution test with three other nurses. v v v v v v v
B.) Have the chief nursing officer interview with the nurse.v v v v v v v v
C.) Hold a root cause analysis. v v v v
D.) Ask other nurses if the staff nurse is trustworthy. - CORRECT ANSWER -
v v v v v v v v v v v v
A.) Perform the substitution test with three other nurses. v v v v v v v
To improve culture of safety survey results, which of the following should an organization do?
v v v v v v v v v v v v v v
A.) Acknowledge and celebrate high-performing areas in front of leadership. v v v v v v v v
B.) Perform root cause analysis on underperforming units to better understand theirVresults.
v v v v v v v v v v
C.) Examine high-performing units to identify and disseminate best practices. v v v v v v v v
D.) Offer coaching and apply Just Culture principles to leaders in lower performing areas. -
v v v v v v v v v v v v v
CORRECT ANSWER -C.) Examine high-performing units to identify and disseminate best practices.
v v v v v v v v v v v v
In which of the following activities would a patient safety specialist engage to promote a culture of saf ety?
v v v v v v v v v v v v v v v v v v
A.) Instruct team members to act in a safe and respectful manner. v v v v v v v v v v
B.) Focus on a list of projects identified by senior stakeholders. v v v v v v v v v
C.) Review annual data on defects and successes. v v v v v v
D.) Apply best evidence with the goal of failure-free operation over time. - CORRECT ANSWERV-
v v v v v v v v v v v v v
D.) Apply best evidence with the goal of failure-free operation over time.
v v v v v v v v v v v
As your organization's patient safety officer, you are reviewing unit results on the AHRQ Culture of S afety
v v v v v v v v v v v v v v v v v
Survey. You are speaking with the manager of a unit for which the unit percent positive score is 30
v v v v v v v v v v v v v v v v v v v
percent for the following statement: "Staff in this unit work longer hours than is best for patient car e."
v v v v v v v v v v v v v v v v v v v
