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