CPPS Review Course

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)

Just Culture

You are charged with identifying and recommending a new event reporting system for your organization. Which of the following would be the best technique to use when evaluating new software systems? A.) Invite senior leaders of the organization to a workshop to ask questions of the software vendor. Review leader evaluations following the workshop. B.) Conduct an open vendor fair for all staff to review various options. Evaluate written and verbal feedback on the systems from participants. C.) Survey your peers across the nation to determine the most popular vendor. Recommend the vendor that is referenced most frequently. D.) Develop a "Request for Proposal" to submit to various software vendors. Evaluate the best responses to make a recommendation.

B.) Conduct an open vendor fair for all staff to review various options. Evaluate written and verbal feedback on the systems from participants.

A medication error at a nearby hospital has recently received media attention. In examining your own organization, you find similar processes are in place to the ones that contributed to the error. You'd like to change your hospital's processes but worry people will be resistant to change. What would be the best method to use to influence others as to the need for change? A.) Reference accreditation standards and hospital policy as the need to make a change in process. B.) Present the story in conjunction with your own facility's data. C.) Develop a staff recognition program for reporting actual events that occur in your facility. D.) Conduct a root cause analysis on a similar event that has occurred at your own facility.

B.) Present the story in conjunction with your own facility's data.

A nurse on a medical-surgical unit does not comply with the barcode medication administration (BCMA) procedure while caring for one of her patients. Her supervisor is deciding how to respond. As her supervisor, what would you do? A.) Ask the nurse what was occurring at the time, and why she chose to bypass the policy. B.) Counsel the nurse on the importance of following policy C.) Ask staff if there are adequate scanners to meet their needs. D.) Request that the pharmacy run a report of the BCMA compliance rates of the unit.

A.) Ask the nurse what was occurring at the time, and why she chose to bypass the policy.

Which of the following is the best first step in changing the culture of safety in a health care organization? A.) Conduct an assessment and gather focused data. B.) Develop, policies, procedures, and checklists for safety. C.) Hire an experienced patient safety officer with a strong performance record. D.) Implement communication and teamwork tools.

A.) Conduct an assessment and gather focused data.

Which of the following chart types would be best to demonstrate non-random process variation over time? A.)Control chart B.) Run chart C.) Bar chart D.) Pie chart

A.) Control chartThe best answer is a control chart because it has controls associated with it (both upper and lower control limits) to provide the clearest picture of change over time. Run charts also display change over time but lack the control limits. Bar charts and pie charts are indicative of descriptive statistics and don't allow you to look at something over time or track progress.

Regulatory and accreditation standards/requirements can help guide improvements by first: A.) Defining required topics of performance B.) Fining people who don't participate C.) Outlining specific targets for performance D.) Providing language for metrics defined in the improvement project

A.) Defining required topics of performance First, regulation defines requirements for performance, and then, often, regulation defines the target to achieve. Outlining specific targets for performance is correct but would follow after defining required topics of performance.

Which of the following changes to operations would best highlight leadership's commitment to patient safety? A.) Executive leadership regularly participating in leadership rounds and daily safety briefings B.) The hospital executive reporting on patient safety at every board meeting C.) Implementing quarterly town hall meetings to share organizational information D.) Including an executive representative on all root cause analysis teams

A.) Executive leadership regularly participating in leadership rounds and daily safety briefings

Which of the following error-reduction strategies is considered the strongest in preventing errors? A.) Fail-safes B.) Education C.) Standardization D.) Checklists

A.) Fail-safes Correct Answer:Fail-safesFail-safes are the strongest strategy to prevent errors because even if the person fails, there is a back-up that keeps the error from occurring. Education relies on memory, so it's a fairly weak strategy. Standardization and checklists are moderate strategies to prevent errors.

The patient safety team reviewed a sample of patients who had been readmitted within 48 hours of discharge and noticed that a patient's discharge medication lists had not been accurately reconciled. The appropriate next steps for the team to take include: A.) Gather data on the accuracy and timeliness of medication reconciliation. B.) Ask nursing to be responsible for all medication reconciliation. C.) Reprimand the discharging provider. D.) Gather a team of key stakeholders to create a flow map for the medication reconciliation process.

A.) Gather data on the accuracy and timeliness of medication reconciliation. Logically, it would be valuable to validate there's a real problem by gathering more data before assembling a group to work on the issue. If there is a problem with reliability of this process, a good next step would be to map the process to look for defects or efficiency barriers.

You are a patient safety officer for a community hospital that has had many falls resulting in serious injuries. A "No Pass Zone" initiative was piloted on one of the units several months ago. You are scheduled to present the results of the pilot to leadership. Your goal is to get leadership's buy in to implement the "No Pass Zone" initiative throughout the entire hospital. What chart would be best to show leadership the impact of the "No Pass Zone" initiative over time? A.) Run chart B.) Pareto chart C.) Shewhart chart D.) Control chart

A.) Run chart A run chart studies variation in data over time and is the best option to help the hospital leaders understand the impact of changes on measures.In regard to the other answer options: A Pareto chart focuses on areas of improvement with greatest impact. Shewhart charts, also known as control charts, distinguish between special cause and common causes of variation. A control chart could be used in this instance, but a run chart is simpler and would be sufficient to answer the key question about improvement over time.

A team is reviewing a serious harm event through the root cause analysis process. Before it draws any conclusions about the accountability of the provider(s) involved, what elements should the team consider? A.) The contribution of systems factors on the individual's behavior B.) How many years the individual has been practicing C.) The individual's most recent performance review D.) Whether the individual filed a claim with risk management

A.) The contribution of system factors on the individual's behavior. The contribution of systems factors on the individual's behavior reflects just culture principles and the proper approach to use before drawing conclusions about accountability.

A patient safety professional wants to ensure engagement of employees in a new patient safety initiative in the hospital. He should: A.) Use staff recommendations for workflow. B.) Collect data on previous initiatives. C.) Communicate the purpose of the initiative to the governing board. D.) Train staff on patient safety principles.

A.) Use staff recommendations for workflow.

Your hospital's leadership is concerned about low safety culture survey scores in the category of "communication openness." The percentage of positive responses related to questioning someone with higher authority is well below national averages. The lead patient safety professional has been asked to make recommendations on increasing the questioning of those with higher authority. To maximize risk reduction, when should staff be asked to stop and question a situation? A.) When something doesn't seem right B.) When a protocol was not followed C.) When discrepancy has been confirmed D.) When patient harm is likely

A.) When something doesn't seem right

The requirement to perform manual independent double checks (IDCs) to reduce errors in the administration of high-alert medications is common in US hospitals. The Institute for Safe Medication Practices (ISMP) recommends that IDC be used judiciously and for only very selective tasks, not for all high-alert medications. The rationale for ISMP's recommendation is: A.) Given the workload requirements in today's hospitals, staff members do not have adequate time to perform IDC for all high-alert medications. B.) Research has demonstrated that IDCs are not effective. C.) Hospitals have reversal agents available to treat most accidental medication overdose D.) The advent of computerized prescriber order entry (CPOE) systems has reduced the potential for hospital medication errors to a negligible level.

A.) Given the workload requirements in today's hospitals, staff members do not have adequate time to perform IDC for all high-alert medications. According to ISMP, correctly double-checking all high-alert medications could add 20 minutes to the nurse's day, a workload that most organizations would not find sustainable.In regard to the other answer options: While hospitals do have reversal agents, a far better practice is to prevent the error in the first place. CPOE systems have prevented many errors, but many errors remain. Research has demonstrated that IDC done correctly is effective, but IDC is most often not done correctly.

Which of the following statements best describes the science of human factors? A.) It is applied to address problems by modifying the design of the system to better aid the people in it. B.) It is about eliminating human error. C.) It consists of a set of principles that can be learned during training. D.) It represents the intersection of medicine and engineering.

A.) It is applied to address problems by modifying the design of the system to better aid the people in it. Human factors science can't eliminate errors, but it can be applied to help modify the design of the system to aid people in performing better, given their limitations as human beings.

A patient safety officer has been asked to compare the incidence of medication omissions on two medical surgical units. To normalize the data, the patient safety officer should compare the: A.) Medication omissions per administered dose on each unit B.) Total number of medication errors on each unit C.) Total number of medication omissions on each unit D.) Medication errors per administered dose on each unit

A.) Medication omissions per administered dose on each unit The patient safety officer has been asked to look at medication omissions, not all medication errors, so medication omissions per administered dose on each unit would be the correct answer. To normalize the data for accurate comparison, the patient safety officer needs to compare rates (as opposed to total numbers).

An example of a descriptive statistics measure for central tendency is: A.) Mode B.) Range C.) Standard error of the mean D.) Standard deviation

A.) Mode Mode is a measure of central tendency. Range, standard deviation, and standard error of the mean are measures of variation.

A vaginal sponge left in a patient was discovered four days after the patient was discharged from the hospital. Investigation revealed the procedure the surgical team applied for counting sponges was inconsistent with the facility's sponge count policy. This inconsistency had developed over a period of time, until staff could not state what the correct counting procedure should be. Which of the following concepts best explains what happened? A.) Normalized deviance B.) Malicious intent C.) Workarounds D.) Checklist fatigue

A.) Normalized deviance Normalized deviance refers to the phenomena in which workarounds become accepted as the norm. (Workarounds are deviations from the standard process that usually happen because the process is in some way flawed, e.g., in this case, maybe two people were required to count but there weren't always two people available.) Malicious intent is highly unlikely to be the cause here. Checklist fatigue may lead to workarounds, but that does not appear to be what happened here.

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.

A.) Perform the substitution test with three other nurses.

You have been asked to present an overview of safety events to your hospital's board of trustees. In order to best represent safety issues, you should: A.) Present cases of harm with contributing root causes and actions taken. B.) Highlight system-wide improvements that have been implemented in the past year. C.) Lead an open discussion of board members' safety concerns and recommendations. D.) Display a graph of the numbers and types of safety events reported in the past year.

A.) Present cases of harm with contributing root causes and actions taken.

Systems thinking encourages organizations to approach cause analysis through: A.) Recognizing people are fallible and experience errors in which system factors are the major cause B.) Understanding individuals alone need to act reliably and avoid error to make patient care safer C.) Acknowledging the system alone is responsible for safety, and all individual failures indicate a deficiency in the system D.) Identifying and removing poor performers to maintain system performance

A.) Recognizing people are fallible and experience errors in which system factors are the major cause Health care has made strides in realizing errors occur because there are imperfect people working in imperfect systems. Removing "poor performers" without addressing systems issue will not prevent adverse events from recurring; in most cases, there were failures further upstream from the event that allowed it to occur.In regard to the other answer options: Acknowledging the system alone is responsible is inaccurate because, at times, there are individual failures when the system in place did not fail. Telling individuals to "act reliably" will not prevent human error or make systems safer.

Referring to the story of the nurse named Karen: Which of the following are human factors issue that contributed to the event? Choose all that apply. Hand-off problems Fatigue Distractions Reliance on memory Look-alike equipment

All of the possible answers are correct. There were hand-off problems and distractions and there was fatigue and reliance on memory.There was also the issue of human nature when Karen first tried to connect the cables; it is human nature to push a little harder when you encounter resistance. Even though there had been some ergonomic and design elements to prevent the cables being connected, with enough force she was able to make the connection.This story does a good job illustrating the system as a whole and how all parts contribute to the outcome. Any shift or change in one of those parts is going to influence the ultimate outcome of that system.

new Cath Lab is under construction in your hospital, and the medical director contacts you to express concerns related to the transport of patients from the Cath lab to the ICU. You agree to assist in the design of a failure mode and effects analysis (FMEA). Components of the FMEA will include: A.) Asking the medical director to participate in leadership rounds in the current Cath lab to identify potential safety risks B.) Assembling a multidisciplinary team whose members will brainstorm potential failures C.) Listing potential root causes of adverse events in the current Cath lab D.) Conducting the Five Whys exercise to figure out what could go wrong

B.) Assembling a multidisciplinary team whose members will brainstorm potential failures Correct Answer:Assembling a multidisciplinary team whose members will brainstorm potential failuresAssembling a multidisciplinary team is the first step in facilitating your FMEA. Five Whys would be done as part of the FMEA, but this will occur downstream, after potential failures are identified.

Which of the following is required to begin the journey to a culture of safety? A.) Care should depend on independent, individual performance excellence. B.) Accountability must be universal and reciprocal, not just top-down. C.) Care should be provider-centered rather than patient-centered. D.) RCA teams must look at errors as individual failures.

B.) Accountability must be universal and reciprocal, not just top-down.

A patient safety professional is monitoring incident reports submitted for near misses and minor events to identify areas of potential patient safety risk. Over the last few months, there has been a steady decline in the number of reports being submitted each week. There have been some leadership changes, but the staff has been stable with no major personnel issues. Which of the following actions should be taken in response to this change? A.) Issue a message to the staff that failure to report can lead to discipline. B.) Ensure reporting is being emphasized and feedback on submitted reports is occurring. C.) Report the data as a positive trend and celebrate the improved performance. D.) Continue to monitor for fluctuations; no action is required at this time.

B.) Ensure reporting is being emphasized and feedback on submitted reports is occurring. James Reason said a reporting culture is required to create a strong safety culture. Leaders should positively reinforce reporting without threats of discipline. To maintain reporting, reporters need feedback that indicates the reports are being used. A decline in reporting is not a positive situation because it suggests problems remain unreported and unresolved.

Your hospital is considering implementing a robotic surgery program. As a patient safety professional, you are concerned about the potential for patient injury associated with this new technology. The most appropriate tool or technique for assessing potential risks associated with implementation of the new technology is: A.) Meaningful use evaluation B.) Failure modes and effects analysis (FMEA) C.) Patient safety leadership WalkRounds D.) Root cause analysis (RCA)

B.) Failure Modes and Effects Analysis (FMEA)The best answer is FMEA. FMEA is a prospective risk reduction strategy; ideally, it is used before a new technology is implemented to determine how the new technology might fail and cause harm. Patient safety leadership WalkRounds are designed to help leaders gather facts about the care environment and create positive relationships between staff and administration. Root cause analysis is a retrospective tool; it is used after a harmful event or near miss to determine what went wrong. Meaningful use evaluation is for evaluating the success of implementing an electronic health record.

What is the best strategy or technique to identify and eliminate known and/or potential problems and errors from a system, design, process, and/or service before they occur? A.) Plan-Do-Study-Act (PDSA) B.) Failure modes and effects analysis (FMEA) C.) Define, Measure, Analyze, Improve, and Control (DMAIC) D.) Root cause analysis (RCA)

B.) Failure modes and effects analysis (FMEA) Correct Answer:Failure modes and effects analysis (FMEA)FMEAs are used to proactively mitigate risk and attempt to identify failures before they occur. PDSA is an iterative problem solving model for process improvement. RCA is used in response to an event to attempt to get to the root problem or cause. DMAIC refers to a data-driven improvement cycle.

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is a process improvement program that can be used to: A.) Eliminate variation. B.) Help address disruptive behavior. C.) Find the root cause of an incident. D.) Reduce waste.

B.) Help address disruptive behavior TeamSTEPPS can be used to increase communication skills with teams and reduce the risk of miscommunication that can lead to disruptive behavior.In regard to the other answer options: Finding the root cause of an incident is performing a root cause analysis. Reducing waste is Lean process improvement, and eliminating variation is Six Sigma.

A nurse is preparing to take medication to Patient A. On the way to Patient A's room, Patient B calls out for immediate assistance. The nurse goes to assist Patient B. After helping Patient B, the nurse gives Patient B the medication intended for Patient A. This scenario is most clearly an example of which of the following? A.) Sentinel event B.) Human error C.) Behavioral choice D.) System failure

B.) Human error Giving a medication to the wrong patient when distracted is a human error. The nurse did not make a behavioral choice and the system did not fail. A sentinel event occurs if death or major permanent loss of function occurs.

Your patient safety team performs a root cause analysis on a recent wrong-side surgery event. Which of the following action items reflects the highest level of reliability? A.) Change the color of surgical site markers from black to red. B.) Implement a process in which the surgical technician holds the scalpel (and does not hand it to the surgeon) until a timeout with all team members at attention has taken place. C.) Educate surgeons to be present for surgical timeouts. D.) Every month, perform multidisciplinary simulations empowering all staff to speak up for safety.

B.) Implement a process in which the surgical technician holds the scalpel (and does not hand it to the surgeon) until a timeout with all team members at attention has taken place.

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.

B.) Investigate system failures and recognize the employee for reporting a near-miss event.

In December 2018, a hospital reports a clostridium difficile infection rate of 8 percent and begins a series of infection prevention measures to reduce hospital-acquired infections in general, including the use of stronger anti-bacterial cleaners throughout the hospital and a hand hygiene awareness campaign. In December 2019, this hospital reports a clostridium difficile infection rate of 4 percent. What conclusion would you draw from this data? A.) The hospital was successful in reducing their clostridium difficile infection rate in 2019. B.) No conclusions can be drawn. C.) Multiple infection prevention efforts are needed to drive down clostridium difficile infection rates. D.) The hospital reduced their clostridium difficile infection rate, though one cannot tell which intervention was most effective.

B.) No conclusions can be drawn.The best answer is that no conclusions can be drawn. Simple comparisons between two values, no matter how easy they are to make or how intuitive they appear to be, cannot fully convey the behavior of data collected over time: both numbers are subject to the common cause variation that is inevitably present in all data. The only way to get a complete picture of what's happening in your organization is to graph data over time, e.g., trended data with multiple data points.

Shortly after the introduction of a new barcode reader, a nurse made an error during medication administration. In the organization's reporting tool, the cause of the error was documented as "the unit was short staffed." A root cause analysis was performed and revealed that there was a failure of the barcode reader that contributed to the nurse bypassing the barcode process. Which high-reliability principle was applied in identifying the cause of error? A.) Resiliency B.) Reluctance to accept simple explanations C.) Deference to expertise D.) Sensitivity to operations

B.) Reluctance to accept simple explanations Per Drake (2016), reluctance to accept simple explanations for problems means that you dig deeper to find answers. In this case, the organization performed a root cause analysis rather than accepting that the unit was simply short staffed.In regard to the other answer options: Resiliency refers to the ability to bounce back quickly and adapt to changes. Sensitivity to operations acknowledges that operations are complicated and ever changing, and deference to expertise is seeking out best practices.

To improve patient safety at transitions of care, the patient safety specialist supports organizational systems to: A.) Prioritize cost efficiency. B.) Restructure design to support clinician workflow. C.) Promote workarounds to ensure timely patient discharge. D.) Deliver discharge instructions verbally to all patients.

B.) Restructure design to support clinician workflow. A systems approach to transitions of care would involve redesigning processes to support clinician workflow to complete the right steps at transitions of care, which are inherently a risky time.In regard to the other answer options: Workarounds are not systems solutions to problems; they are ways that staff get the work done despite barriers in the correct process. Delivering discharge instructions verbally to patients may be a step to consider in a process redesign, but systems analysis would encourage the redesign team to think about how to support patients to follow instructions without relying on memory. Finally, cost efficiency should not be prioritized over safety in transitions in care.

A medication error is self-reported by a nurse to the risk manager. The manager tells the nurse to complete an incident report. Upon review of the patient safety event, the manager notices that the nurse overrode a safety check on the barcode scan system. Further review of the "override" report reveals that several other nurses have also overridden the system. The risk manager further investigates and finds out that there was an issue with the printer in registration on that day, which meant that the barcode scanner could not read the patient ID bracelets. This is an example of what type of analysis? A.) Failure mode and effects analysis B.) Root cause analysis C.) Event report analysis D.) Process analysis

B.) Root cause analysis Correct Answer:Root cause analysis-Root cause analysis is a methodical investigation of the error/event by continuously asking why until you come to the actual cause of the error. Failure mode and effects analysis is usually performed when rolling out something new. Event report analysis is a description of what happened, not necessarily the cause. Process analysis looks at how something is done, rather than why something happened.

During daily rounding, a vice president observed a problem in a particular device that impacts delivery of care. He shared the information with other senior executive team members, and, upon further investigation, they learned that the issue was common. The findings resulted in the organization replacing the defective devices in all affected areas. Which of the following high-reliability principles did the leaders of this organization apply? A.) Deference to expertise B.) Sensitivity to operations C.) Resiliency D.) Reluctance to accept simple explanations

B.) Sensitivity to operations

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

B.) Teach-back

A new medication administration safety process was implemented in a hospital. A team convened to perform a failure mode effects analysis (FMEA) and calculate a risk priority number (RPN). After a targeted medication safety program on the new process was delivered to nurses, the same team was convened to perform another FMEA. Which of the following would the team be happy to see? A.) The frequency numbers increased and RPNs were lower. B.) The detectability increased and RPNs were lower. C.) The frequency numbers decreased and RPNs were higher. D.) The detectability decreased and RPNs were lower.

B.) The detectability increased and RPNs were lower. Correct Answer:The detectability increased and RPNs were lower.The team would be seeing an improvement if the detectability was higher, meaning safety risks and defects were easier to identify and therefore resolve. It's important to note that detectability has an inverse scale, so higher detectability gets a lower score reflecting lower risk. The RPN represents the overall risk of harm, so improvement would be occurring if that number decreased.

When an adverse event occurs with a patient: A.) An investigation should commence to determine the staff member at fault. B.) The event should be openly discussed with the patient, family, and staff. C.) A root cause analysis should be completed and submitted to the Joint Commission. D.) The patient should not be told about the event because of the possibility of legal action.

B.) The event should be openly discussed with the patient, family, and staff.

A root cause analysis team has recommended the following action item: "The manager will provide the care team with training on the proper use of personal protective equipment required while caring for a patient with tuberculosis." Which of the following is a process measure the team might use? A.) The number of personal protective equipment purchased B.) The percentage of staff observed to be correctly using personal protective equipment C.) Percentage of staff with positive TB skin tests D.) The number of reported staff exposures to tuberculosis

B.) The percentage of staff observed to be correctly using personal protective equipment The percentage of staff observed to be correctly using personal protective equipment is the best example of a process measure. The other answer options are examples of outcome measures.

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%

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%.

A recent hospital initiative to decrease venous thromboembolism (VTE) was not successful, despite implementing a training program for staff. An interprofessional team came together to analyze the persistent problem. Pharmacists reported that patients often refused anticoagulant injections, particularly the midnight dose. Nurses reported that patients did not care to be awakened and given an injection, and, other times, nurses withheld the injection because the patient was walking to the bathroom. Which of the following steps is the most important for the team to take to address this problem? A.) Share the data with decision makers and continue to monitor run charts. B.) Use the Plan-Do-Study-Act (PDSA) cycle method for improvement. C.) Require staff to attend an annual training on professional guidelines. D.) Request that pharmacy and nursing brainstorm solutions with their staff.

B.) Use the Plan-Do-Study-Act (PDSA) cycle method for improvement. PDSA cycles can help the team test various ideas for improvement to see which one leads to the best results. Requiring staff to receive more education may not help if the staff are already aware of what they're expected to do and why. Brainstorming solutions may be useful, but it won't lead to improvement without the steps the team would take in conducting PDSA cycles. It's important to monitor the data, but measurement alone does not lead to improvement, as improvement requires change.

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.

B.) Using an appropriate accountability system, counsel the surgeon about customary clinical standards.

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 30 percent for the following statement: "Staff in this unit work longer hours than is best for patient care." What do you tell the manager the positive answer in this statement means? A.) 30% of the staff agree with the statement. B.) 30% of the staff work longer hours. C.) 30% of the staff disagree with the statement. D.) 70% of the staff work longer hours.

C.) 30% of the staff disagree with the statement.

A strategy used to overcome failure in a process is the use of a checklist. To match the limit of working memory, a good rule when creating a checklist is to keep the number of tasks between how many items? A.) 1 and 5 B.) 3 and 10 C.) 5 and 9 D.) 10 and 15

C.) 5 and 9. Psychologists who study human memory recommend keeping the number of items between five and nine, which is the maximum number the human memory can remember.

Which of the following descriptions best reflects principles of safe system design? A.) A hospital routinely utilizes control charting to report safety performance. B.) A hospital routinely reviews and updates policies and procedures every two years. C.) A hospital routinely studies close calls. D.) A hospital routinely provides trainings on the use of newly introduced medical equipment.

C.) A hospital routinely studies close calls. Routinely studying close calls is where the hospital will get the most "bang for its buck" in terms of coming up with safer design. Training, policies and procedures, and control charts all may be helpful to promote safety but do not represent foundational principles of safe system design.

A hospital board wants to know how its safety performance in central line-associated blood stream infections (CLABSIs) compares to that of other hospitals in their region. Which data display would best inform them for that decision? A.) A written report summarizing the current CLABSI prevention protocols of each hospital in the region B.) A table showing the number of CLABSI infections in each hospital in the region by quarter for the past two years C.) A table indicating the CLABSI infection rates of all hospitals in the region relative to the National Healthcare Safety Network benchmark for CLABSI infections for the past two years D.) Control charts of overall infection rate by quarter for the past two years for each hospital in the region

C.) A table indicating the CLABSI infection rates of all hospitals in the region relative to the National Healthcare Safety Network benchmark for CLABSI infections for the past two years The correct answer is a table indicating the CLABSI infection rates of all hospitals in the region relative to the National Healthcare Safety Network benchmark for CLABSI infections for the past two years.In regard to the other answer options: Reporting an overall infection rate does not tease out CLABSI infections specifically. Written descriptions of protocols may not include performance data and would be harder to digest and find comparable information to guide decision making. Counts of CLABSI infections alone would not communicate enough information for decision making. Large hospitals may have more infections than smaller hospitals because of their size or patient acuity levels, so looking at rate would make performance more comparable across hospitals.

A hospital is attempting to engage the board in their quality endeavors. Which is the best strategy to improve the board's involvement? A.) Focus only on measures that are tied to reimbursement. B.) Report all quality measures to the board. C.) Align the quality measures with the hospital's strategic goals. D.) Set only goals that can be attained.

C.) Align the quality measures with the hospital's strategic goals.

Your organization is preparing to change to a new electronic health record. Many departments have been involved with the planning for this huge effort. What would you suggest as part of the preparation strategy? A.) Suggest a Plan-Do-Study-Act (PDSA) cycle. B.) Offer to do a claims analysis for any related errors. C.) Conduct a failure modes and effects analysis (FMEA). D.) Conduct a root cause analysis (RCA).

C.) Conduct a failure modes and effects analysis (FMEA). Correct Answer:Conduct a failure modes and effects analysis (FMEA).FMEA would be valuable step for anticipating gaps in the planning so that people can address potential problems before implementing the new system. A PDSA cycle would be a good way to test and implement any changes, but it wouldn't help diagnose problems.

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.

C.) Examine high-performing units to identify and disseminate best practices.

On an anesthesia machine, incompatible connectors prevent connecting an anesthetic gas to the oxygen port. What concept does this best exemplify? A.) Resiliency B.) Standardization C.) Forcing function D.) Workaround

C.) Forcing function A forcing function is a design concept that makes it impossible to do the wrong thing. Workarounds, which are often unsafe, are defined as processes staff create to accomplish a task because of a barrier within the recommended process. Standardization is a method to reduce the chance of error by reducing the variation in how the same process is done.

In cause analysis, the role of the Executive Sponsor is to: A.) Coordinate all efforts of the cause analysis team and conduct performance management discussions. B.) Prepare for a visit by the department of health if the event meets criteria for reporting to the state. C.) Help scope the objectives and maintain accountability for effective and timely action plans. D.) Complete the initial debrief following a patient safety event and ensure the safety of all involved.

C.) Help scope the objectives and maintain accountability for effective and timely action plans.

A serious adverse event resulting in a patient death has occurred at your facility. What is the first step in the root cause analysis process? A.) Perform individual interviews with involved staff members. B.) Gather appropriate information. C.) Identify RCA team members. D.) Identify factors that contributed to the event.

C.) Identify RCA team members. Correct Answer:Identify RCA team members.The first step in an RCA is to form the team, which then gathers the appropriate information, identifies factors contributing to the event, and interviews staff members involved.

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

C.) Identify potential safety implications, employ countermeasures to mitigate any anticipated risks, and monitor the change

You are meeting with your organization's CFO to review the likely Return on Investment (ROI) for several possible patient safety initiatives. Based only on the projected ROI, which project is most likely to receive the CFO's approval? A.) Implementation of Computerized Provider Order Entry to reduce the number of medication errors with an ROI of 1.0, or 100 percent. B.) Procurement of new beds with built-in alarms to reduce falls with an ROI of 0.9, or 90 percent. C.) Implementation of evidence-based guidelines to reduce the rate of catheter-associated urinary tract infections with an ROI of 3.0, or 300 percent. D.) Implementation of a sitter program, which has been shown to reduce falls and improve patient satisfaction with an ROI of 0.5, or 50 percent.

C.) Implementation of evidence-based guidelines to reduce the rate of catheter-associated urinary tract infections with an ROI of 3.0, or 300 percent.

Why is it important to share lessons learned from RCAs? A.) It exposes the fallibility of the clinician(s) involved. B.) It allows others to introduce workarounds to avoid the same situation. C.) It allows co-workers to learn the rationale for why an event occurred and incorporate new lessons learned into practice D.) Sharing these events should not be encouraged because it increases the risk of litigation.

C.) It allows co-workers to learn the rationale for why an event occurred and incorporate new lessons learned into practice. Sharing allows others to adopt new methods and to heighten risk awareness. In regard to the other possible answers: The goal of an RCA is not to place blame on individual clinicians, and workarounds are oftentimes unsafe practices that ignore systems issues that require fixing. Sharing lessons learned from an RCA may decrease the risk of litigation by improving patient safety and reducing the likelihood of an adverse event occurring again.

In the context of failure modes and effects analysis (FMEA), how is the risk priority number (RPN) used? A.)It calculates the failure modes that will create the most errors. B.) It specifies the failure modes that have been shown to cause harm. C.) It identifies the highest priority failure modes to address. D.) It prioritizes the failure modes that do not require action.

C.) It identifies the highest priority failure modes to address. The Risk Priority Number (RPN) is a score that provides the team a way to identify the highest risk failure modes in descending order. If the team does not have the resources to address all the identified risks, this number can be used to filter out failure modes that are acceptable in the current state.In regard to the other answer options: The RPN does not determine that an action is not required; that determination comes from the team evaluating the issue at hand, and, to some degree, may be decided based on time and resources available. The RPN does not identify error potential or represent harm that has already occurred; it identifies the impact of a failure mode if it does occur.

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

C.) Psychological safety

In reviewing patient safety events over the past year, a team determines that the majority of the events were caused by poor communication among team members. Which tool should the team recommend to standardize the way providers communicate at handoffs or transitions of care? A.) DESC B.) AIDET C.) SBAR D.) CUS

C.) SBAR SBAR (Situation, Background, Assessment, Recommendation) is a technique for communicating critical information that requires immediate attention and action concerning a patient's condition.In regard to the other answer options: AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank You) is a Studer method to communicate with patients and their family and friends. DESC (Describe the specific situation; Express your concerns about the action; Suggest other alternatives; Consequences should be stated) is a constructive approach for managing and resolving conflict from the TeamSTEPPS curriculum. CUS is an acronym used for key words (I am Concerned; I am Uncomfortable; This is a Safety issue) to "stop the line" when a safety concern arises.

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.

C.) The biopsy samples from a colonoscopy are never received by pathology after the procedure.

Your health system learns about an incident involving a retained sponge following surgery, and an RCA will be performed. The root cause analysis is credible if: A.) A single, clearly defined root cause has been identified. B.) It is reviewed and signed by a patient safety professional. C.) There is participation by leadership and individuals closely involved in the process. D.) Corrective actions have been developed and completed.

C.) There is participation by leadership and individuals closely involved in the process. The Joint Commission Comprehensive Accreditation Manual for Hospitals states that RCAs for sentinel events, such as this, will be considered acceptable if they are thorough and credible with "credible" defined as: 1) including participation by leadership and individuals most closely involved in the process and 2) internally consistent (i.e., the RCA does not contradict itself).

The free, uninhibited flow of information that is open to the scrutiny of others is the definition of: A.) Quality care B.) Just Culture C.) Transparency D.) High reliability

C.) Transparency

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.

D.) Apply best evidence with the goal of failure-free operation over time.

Centralized appointing staff are expected to use appointing guidelines to ensure patients with urgent needs are seen promptly. After several delays in scheduling appointments that should have been treated as urgent, what would be the strongest action to prevent future mistakes? A.) Ensure guideline updates are communicated to all schedulers. B.) Educate schedulers about the importance of using the scheduling guidelines. C.) Remind schedulers to use the scheduling guidelines for every patient and not just when uncertain. D.) Build the scheduling guidelines into the electronic appointing system.

D.) Build the scheduling guidelines into the electronic appointing system. The best answer is to build the scheduling guidelines into the electronic appointing system. The other answers represent weaker actions to prevent errors.

You are the charge nurse on a busy ICU. It is 11:00 PM, and one of your nurses needs to leave for a family emergency. Which of the following actions is the most appropriate next step? A.) See if this is an established pattern for this nurse. B.) Take on the nurse's patients for the rest of the shift. C.) Reassign the nurse's patients to the most senior nurse on the unit. D.) Call a huddle to reassign resources and establish a contingency plan.

D.) Call a huddle to reassign resources and establish a contingency plan.

When setting organizational safety priorities, it is best to: A.) Review the current literature to identify areas of frequent concern. B.) Focus primarily on accreditation standards and requirements. C.) Determine priorities based on pay-for-performance measurements. D.) Develop a mechanism to gather input from a variety of sources.

D.) Develop a mechanism to gather input from a variety of sources.

The leader of a hospital division wants to know if her division's safety (incident) reporting rate is steady or, hopefully, increasing. She is considering using one of the following two data displays: Graph A=Bar Graph Graph B=Control Chart A.) Graph B because it shows many data periods B.) Graph A because it shows volume compared to other divisions C.) Graph A because it shows year-to-date performance D.) Graph B because it shows a report number adjusted for patient volumes

D.) Graph B because it shows a report number adjusted for patient volumes Graph B is the correct answer because it shows a report number adjusted for patient volumes, allowing us to see the true trend of reporting. Using counts to determine whether a reporting volume is steady or rising does not take into account factors that may influence that reporting volume, such as patient census. Using a denominator helps to normalize our interpretation of a count. (Although it is true graph B shows many data points, the same purpose could still be achieved with fewer data points.)Graph A is not correct because this graph reflects count data and only one point in time. (Using Graph A, the division leader may conclude that her division is performing moderately well compared to other divisions, but, again, this graph shows one point in time.) If the bars were a rate of reporting by division (such as by adjusted patient days), the leader could at least determine if there were a comparable rate based on patient volumes.

Your organization utilizes a "home grown" electronic safety event reporting system that is no longer meeting the needs of the organization. Hospital administration is asking for your opinion: What would you do for next steps to identify a replacement system? A.) Purchase the least expensive software. B.) Ask Information Systems to either fix the old system or build a new one. C.) Poll colleagues and purchase what they use. D.) Identify key stakeholders and perform a gap analysis of current state to ideal state.

D.) Identify key stakeholders and perform a gap analysis of current state to ideal state. Performing a thorough search of available products that meet the standards for the organization is the primary action you should take. Once the collated information is obtained, convening a meeting with the key stakeholders (nursing, medicine, finance, patient safety, legal, etc.) to determine the organizational needs in relation to the intended financial impact and return on investment may be required.

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

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

Hospital leadership has just learned of the reoccurrence of a type of sentinel event that has not occurred in a long time, which they believed to have been permanently resolved. Which of the following possible explanations for the recurrence seems most likely? A.) Negative changes in culture have reduced event reporting B.) Drift to old habits over time has slowly eroded safer practice. C.) Staff are not familiar with safety policies and protocols due to significant turnover. D.) Leadership has stopped messaging on safety because significant time has passed since the last sentinel event.

D.) Leadership has stopped messaging on safety because significant time has passed since the last sentinel event.

A patient safety professional wants to enhance a culture of reporting by introducing a visual tool that quickly provides the opportunity for frontline staff to share defects, promote their risk awareness, and share in resolution of defects. The most suitable tool is: A.) Failure modes and effects analysis B.) Patient safety leadership WalkRounds C.) Root cause analysis D.) Learning boards

D.) Learning boards A learning board is a visual tool that enhances frontline staff participation in the resolution of defects. The other options to do meet the criteria mentioned: Failure modes and effects analysis is a proactive tool for risk assessment. Root cause analysis happens after reporting. Patient safety leadership WalkRounds are not a visual tool.

The Just Culture model includes creating a learning culture, designing safe systems, and which of the following activities? A.) Providing punishment equal to the harm caused B.) Decreasing the amount of reported errors C.) Finding the individual to blame D.) Managing behavioral choices

D.) Managing behavioral choices

Patient safety themes linked to improvement of medication adherence by a patient are: A.) Briefs, huddles, and debriefs B.) Leadership, communication, and patient advocacy C.) Patient and family engagement, health literacy, and transitions in care D.) Medication reconciliation, bedside shift report, and nurse double-check

D.) Medication reconciliation, bedside shift report, and nurse double-check Correct Answer:Patient and family engagement, health literacy, and transitions in carePatient and family engagement, health literacy, and transitions in care are patient safety themes to improve medication adherence. Medication reconciliation, shift report, double checks, briefs, huddles, and debriefs are patient safety tools. Leadership, communication, and advocacy are patient safety themes but are not the best choice for themes related to improving medication adherence.

Which of the following is considered to be a scientific method of process improvement for testing a change in a real work setting? A.) Event analysis B.) Root cause analysis (RCA) C.) Failure mode and effects analysis (FMEA) D.) Plan-Do-Study-Act (PDSA) cycle

D.) Plan-Do-Study-Act (PDSA) cycle The PDSA cycle is a scientific method of process improvement that involves planning the change, trying it, observing it, and acting on what is learned. It serves as a guide for testing a change in a real work setting. RCA and event analysis are used mostly in identifying causes related to an adverse event. FMEA is utilized in identifying potential failures before a new process is implemented.

Which of the following tactics is the best approach to increase near-miss event reporting? A.) Include staff names in event reports. B.) Give staff up to a week to report events. C.) Require staff to report all errors and near-misses. D.) Provide event reporters with feedback and follow-up

D.) Provide event reporters with feedback and follow-up

A patient safety professional is developing an action plan as part of a RCA. To best prevent recurrence of the underlying causes the RCA team identified, which of the following types of actions is preferable? A.) Create programs to instruct staff on proper technique in the involved process. B.) Develop checklists for staff to avoid missing steps. C.) Add alerts in the Electronic Health Record to guide decisions. D.) Redesign the workflow to eliminate the steps that fail.

D.) Redesign the workflow to eliminate the steps that fail. Among the answer options listed, only redesigning a process to control for the defect is known to be a strong action to prevent recurrence of an event, as explained in the IHI/NPSF RCA2 paper.The other answer options are all actions that may be appropriate, but they do not stop the potential for the defective step to occur. Humans would still need to take an action or remember to do something, which makes them less reliable solutions than a process re-design.

A patient experienced cardiac arrest while undergoing surgery. During resuscitation, the code team was unable to administer a shock because the defibrillator pads and the defibrillator itself could not be connected. Upon investigation, the patient safety professional discovered that multiple brands of defibrillators existed in the hospital, and they differed in appearance and functionality. What human factors engineering solution should have been implemented? A.) Resilience B.) Forcing functions C.) Usability tests D.) Standardization

D.) Standardization An axiom of human factors engineering is that equipment and processes should be standardized whenever possible, in order to increase reliability, improve information flow, and minimize cross-training needs. Standardizing equipment across clinical settings, as in this defibrillator scenario, is one basic example.

Your hospital implements patient safety WalkRounds as part of a series of changes to improve safety. Six months after the implementation, informal staff feedback suggests inconsistency in the WalkRounds' effectiveness. As the patient safety professional charged with ensuring the success of the effort, what is the best assessment technique to gain insight into current performance? A.) Review information boards in the areas included in the WalkRounds to determine the scope of issues raised. B.) Discuss the informal feedback you have been receiving with the CEO. C.) Gather data about the frequency and content of the WalkRounds to establish current baseline performance. D.) Survey staff and leaders about their views on patient safety WalkRounds.

D.) Survey staff and leaders about their views on patient safety WalkRounds.

An organization has implemented measures to provide preventative health screenings in an effort to prevent disease, delay the onset of disease, keep diseases from worsening, and reduce costs to health care. In order to measure effectiveness of the interventions, leaders of the effort are planning to collect data. Which would be the best process measure for them to look at? A.) The number of patients whose pre-existing conditions improved after having been screened B.) The number of patients who reported adopting a healthier lifestyle as a result of the screening C.) Costs to the organization pre and post implementation of the health screenings D.) The number of health screenings performed

D.) The number of health screenings performed. The only process measure among these options is the number of health screenings performed. The rest are outcome (not process) measures.

A known barrier to patient safety is staff not speaking up when they are concerned or if they see safety violations. Which of the following is the best approach to help foster a culture that supports speaking up? A.) Putting up posters around the organization that reinforce speaking up as a safety strategy B.) Implementing Just Culture tools C.) Using trends in event reporting to identify staff who don't speak up D.) Using culture of safety data to assist low-performing departments with defining strategies for improvement

D.) Using culture of safety data to assist low-performing departments with defining strategies for improvement Using culture of safety data to target departments that are contributing the most to the problem can help build momentum for speaking up across the organization. The Safety Attitudes Questionnaire (SAQ), which specifically asks questions about how well people are encouraged to speak up and about feedback loops, could point to departments most in need of help. Adopting just culture is not an incorrect answer to the question, but using culture of safety data is a more targeted answer.

A hospital's patient safety team is exploring strategies to reduce the number of patient identification errors in the lab specimen collection process. Which of the following strategies will provide the highest impact in reduction of errors? A.) Educate all nurses and phlebotomists to ask about patient identifiers before obtaining specimen. B.) Revise the process to allow only one specimen label on the nurse/phlebotomist tray at a time. C.) Standardize the process to require the nurse/phlebotomist to ask the patient to state their name prior to the specimen collection. D.) Utilize barcode scanners to generate a specimen label at the bedside.

D.) Utilizing bar code scanners is the correct answer because it entails a forcing function at the bedside. After scanning the armband, the correct label for that patient will print from the scanner.In regard to the other options: Education is always the lowest impact (soft fix) in any action plan. Changing processes is better but will still rely on individuals to do the right thing, e.g., the nurse/phlebotomist would need to make sure multiple labels were not on the tray, which is a common shortcut to avoid having to walk back and forth between specimen collections. Direct observation would be required to make sure people didn't introduce workarounds.

This term reflects a group of individuals who understand the importance of self- and group- regulation.

Professionalism

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?

Psychological safety

What are the 3 key areas of Patient Safety leadership?

Strategy, Operations, and Engagement