Certified Professional in Patient Safety Questions and
Answers Latest Update 100% A+
"handoffs" - ✔✔✔transferring responsibility for a patient from one caregiver to another with the goal of providing timely,
accurate information about a patient's plan of care, treatment, current condition and anticipated changes
"signout" - ✔✔✔act of transmitting information about a patient
% of adverse events within 3 wks of discharge - ✔✔✔20%
3/4 prevented or ameliorated
% of healthcare professionals at any level engage in disruptive behavior - ✔✔✔2-4%
% of Medicare beneficiaries in SNF experience an adverse event during their stay and how many were preventable - ✔✔✔22%
half
% of Medicare beneficiaries that are d/c to some form of LTC facilities after hospital stay - ✔✔✔40%
% of Medicare pt re-hospitalized within 30 days of d/c - ✔✔✔20%
% of physicians who develop a substance use disorder - ✔✔✔10-12%
% who reported witnessing physicians engage in disruptive behavior vs. nurses - ✔✔✔77%
65%
1994 Error in Medicine - ✔✔✔Dr. Lucian Leape
highlighted the issue & presented a framework for error analysis and prevention
1999 institute of Medicine Report - ✔✔✔"To err is human: building a safer health system "
toll of medical errors at the national level - 98,000 deaths every year due to preventable harm
no single validated method for measuring eh overall safety of care
,2001 Making Health Care Safer Report - ✔✔✔AHRQ first effort to use evidence-based medicine principles to id practices to
improve pt safety
2003 health literacy results - ✔✔✔over a third had basic or below basic levels
53% had intermediate level
12% proficient
2003 work hours regs impact on pt safety - ✔✔✔no clear effect on pt safety or clinical outcomes
may be due to the number of pt handoffs
burnout and fatigue are still common
2004 Standards for Nursing-Sensitive Care - ✔✔✔markers of nursing care quality and system-related measures including:
- nsg skill mix
- nsg care hrs
- measures of quality of nursing practice env
-nursing turnover
2011 components of fall prevention interventions - ✔✔✔1. multidisciplinary
2. staff and pt ed
3. individualized POC
4. safe footware
5. focus on prevent, detect, and tx delirium
6. culprit meds
7. continence mgmt
8. device, mobility aids, and exercise
9. post fall review
2013 Making Health Care Safer II - ✔✔✔AHRQ added to the evidence based behind pt safety interventions
2015 Annual Perspective on balance systems approach with accountability - ✔✔✔just culture
at risk vs. reckless
, 2015 Free From Harm by the National Patient Safety Foundation - ✔✔✔call for creation of common set of safety metrics that
reflect meaningful outcomes
1. est std set of process and outcome measures for use on a national basis
2. creating measures of pt safety for settings outside the hospital
3. improve the quality of safety reporting systems
4. develop ways of measuring safety in real time
2015 Free From Harm Report - ✔✔✔National Patient Safety Foundation
1. leaders est and sustain a safety culture
2. centralized and coordinated oversight of pt safety
3. create a common set of safety metrics the reflect meaningful outcomes
4. increase funding for research in pt safety and implementation science
5. safety across the entire care continuum
6. support healthcare workforce
7. partner with pt and families
8. ensure technology is safe and optimized
3 tiered support program for 2nd victims - ✔✔✔1. unit or dept based event recognition and support by trained colleagues or
leaders (60% met)
2. trained peer support in high-risk clinical units to monitor, one-on-one support, trigger debriefings, and access to org
resources (30%)
3. access to professional counseling (10%)
Accreditation Council for Graduate Medical Education rules for work hours in 2003 - ✔✔✔1. no more than 80 hours per week
2. no more than 24 consecutive hours on duty
3. not be on call more than every 3rd night
4. must have 1 day off per week
Accreditation Council for Graduate Medical Education rules for work hours in 2017 - ✔✔✔based on Flexibility in Duty Hours
Requirements for Surgical Trainees (FIRST)
same other than no 16 hour shift limit for first-year residents
active errors - ✔✔✔occurring at the point of interface between humans and complex system
Answers Latest Update 100% A+
"handoffs" - ✔✔✔transferring responsibility for a patient from one caregiver to another with the goal of providing timely,
accurate information about a patient's plan of care, treatment, current condition and anticipated changes
"signout" - ✔✔✔act of transmitting information about a patient
% of adverse events within 3 wks of discharge - ✔✔✔20%
3/4 prevented or ameliorated
% of healthcare professionals at any level engage in disruptive behavior - ✔✔✔2-4%
% of Medicare beneficiaries in SNF experience an adverse event during their stay and how many were preventable - ✔✔✔22%
half
% of Medicare beneficiaries that are d/c to some form of LTC facilities after hospital stay - ✔✔✔40%
% of Medicare pt re-hospitalized within 30 days of d/c - ✔✔✔20%
% of physicians who develop a substance use disorder - ✔✔✔10-12%
% who reported witnessing physicians engage in disruptive behavior vs. nurses - ✔✔✔77%
65%
1994 Error in Medicine - ✔✔✔Dr. Lucian Leape
highlighted the issue & presented a framework for error analysis and prevention
1999 institute of Medicine Report - ✔✔✔"To err is human: building a safer health system "
toll of medical errors at the national level - 98,000 deaths every year due to preventable harm
no single validated method for measuring eh overall safety of care
,2001 Making Health Care Safer Report - ✔✔✔AHRQ first effort to use evidence-based medicine principles to id practices to
improve pt safety
2003 health literacy results - ✔✔✔over a third had basic or below basic levels
53% had intermediate level
12% proficient
2003 work hours regs impact on pt safety - ✔✔✔no clear effect on pt safety or clinical outcomes
may be due to the number of pt handoffs
burnout and fatigue are still common
2004 Standards for Nursing-Sensitive Care - ✔✔✔markers of nursing care quality and system-related measures including:
- nsg skill mix
- nsg care hrs
- measures of quality of nursing practice env
-nursing turnover
2011 components of fall prevention interventions - ✔✔✔1. multidisciplinary
2. staff and pt ed
3. individualized POC
4. safe footware
5. focus on prevent, detect, and tx delirium
6. culprit meds
7. continence mgmt
8. device, mobility aids, and exercise
9. post fall review
2013 Making Health Care Safer II - ✔✔✔AHRQ added to the evidence based behind pt safety interventions
2015 Annual Perspective on balance systems approach with accountability - ✔✔✔just culture
at risk vs. reckless
, 2015 Free From Harm by the National Patient Safety Foundation - ✔✔✔call for creation of common set of safety metrics that
reflect meaningful outcomes
1. est std set of process and outcome measures for use on a national basis
2. creating measures of pt safety for settings outside the hospital
3. improve the quality of safety reporting systems
4. develop ways of measuring safety in real time
2015 Free From Harm Report - ✔✔✔National Patient Safety Foundation
1. leaders est and sustain a safety culture
2. centralized and coordinated oversight of pt safety
3. create a common set of safety metrics the reflect meaningful outcomes
4. increase funding for research in pt safety and implementation science
5. safety across the entire care continuum
6. support healthcare workforce
7. partner with pt and families
8. ensure technology is safe and optimized
3 tiered support program for 2nd victims - ✔✔✔1. unit or dept based event recognition and support by trained colleagues or
leaders (60% met)
2. trained peer support in high-risk clinical units to monitor, one-on-one support, trigger debriefings, and access to org
resources (30%)
3. access to professional counseling (10%)
Accreditation Council for Graduate Medical Education rules for work hours in 2003 - ✔✔✔1. no more than 80 hours per week
2. no more than 24 consecutive hours on duty
3. not be on call more than every 3rd night
4. must have 1 day off per week
Accreditation Council for Graduate Medical Education rules for work hours in 2017 - ✔✔✔based on Flexibility in Duty Hours
Requirements for Surgical Trainees (FIRST)
same other than no 16 hour shift limit for first-year residents
active errors - ✔✔✔occurring at the point of interface between humans and complex system
