CPPS IHI Practice Exam

A manager demonstrates adherence to the principles of a just culture by applying which of the following types of decision-making frameworks? A. harm-based B. outcome-focused C. equity-focused D. risk-based

D. risk-based

Which of the following concepts describes a situation where violations of safe practices become regarded as acceptable and are generally tolerated by the group? A. standards of practice B. inattentional blindness C. normalized deviance D. situational bias

C. normalized deviance

Leadership addressed an unrecognized latent threat in an existing workflow that was brought to their attention by frontline workers. This is an example of: A. preoccupation with failure. B. decentralized decision making. C. sensitivity to operations. D. commitment to resilience.

C. sensitivity to operations.

Which of the following is most useful in illustrating inefficiency and waste in a process? A. fishbone diagram B. control chart C. spaghetti chart D. Pareto diagram

C. spaghetti chart

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

A. Align the quality measures with the hospital's strategic goals. If quality/safety measures are aligned with the hospital's strategic goals, this assures that everyone across the system, from the board to the frontline staff, have quality and safety as a point of focus. Reporting all quality measures to the board is too broad and not practical; measures across the system should be rolled into fewer overarching strategic measures that the board can reasonably review.Focusing only on measures that are tied to reimbursement might be a barrier to aligning your quality measures with strategic initiatives, and it could lead to neglect of important areas for improvement. (Notably, the list of outcome measures that the Centers for Medicare & Medicaid Services ties to reimbursement consistently grows; if you focus only on measures currently tied to reimbursement, you could fall behind.)Setting only goals that can be attained is incorrect because it would encourage average performance rather than continuous improvement and excellence.

A 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. Assembling a multidisciplinary team whose members will brainstorm potential failures B. Listing potential root causes of adverse events in the current Cath lab C. Conducting the Five Whys exercise to figure out what could go wrong D. Asking the medical director to participate in leadership rounds in the current Cath lab to identify potential safety risks

A. Assembling a multidisciplinary team whose members will brainstorm potential failures Assembling 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.

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. Identify RCA team members. B. Identify factors that contributed to the event. C. Perform individual interviews with involved staff members. D. Gather appropriate information.

A. 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.

Of the following steps, which should be done first when conducting an FMEA? A. Identify a high-risk process to evaluate. B. Formulate solutions for a high-risk process. C. Develop a ranking method to prioritize actions. D. Facilitate error management strategies.

A. Identify a high-risk process to evaluate.

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. Learning boards B. Patient safety leadership WalkRounds C. Root cause analysis D. Failure modes and effects analysis

A. 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.

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. Root cause analysis B. Event report analysis C. Failure mode and effects analysis D. Process analysis

A. 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. Sensitivity to operations B. Deference to expertise C. Resiliency D. Reluctance to accept simple explanations

A. Sensitivity to operations Sensitivity to operations acknowledges that operations are complex and ever-changing. Leaders who apply this principle of high reliability consistently round, to be able to observe and obtain firsthand knowledge of any obstacles and opportunities. This practice increases attention to patient care processes.

A patient safety professional notes an increase in safety events involving insulin. Which of the following strategies is most likely to result in improvement? A. The quality committee requires monthly progress reports on departmental insulin safety plans. B. The pharmacy and therapeutics committee introduces two insulin products to the formulary. C. The pharmacy educates on insulin safety by distributing a tip sheet to nursing and providers. D. The medication safety committee monitors reports on insulin administration errors.

A. The quality committee requires monthly progress reports on departmental insulin safety plans.

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 discrepancy has been confirmed C. When a protocol was not followed D. When patient harm is likely

A. When something doesn't seem right. A strong safety culture requires open communication and willingness by everyone in the organization to speak up and question conditions and behaviors before they lead to an event. Questioning a situation as soon as something doesn't seem right provides the greatest risk reduction, and any limitation or restrictions on this type of questioning erodes safety. If the expectation is to speak up only when there is a situation of potential harm or procedural violation, there will be missed opportunities.

10. As a result of an adverse drug event, a patient required renal dialysis. A patient safety professional and other leaders are discussing what to disclose to the patient. In addition to an apology, critical components of disclosure include A. a commitment to investigate what happened and how future errors will be prevented. B. who was involved, when it happened, and how often medication errors occur. C. plans for staff disciplinary action, physician disciplinary action, and a plan for education. D. history of pharmacy transcription errors, and the plan to implement an electronic health record.

A. a commitment to investigate what happened and how future errors will be prevented.

Measurement of hospital-acquired pressure injuries would be an example of A. an outcome measure. B. a process measure. C. a balance measure. D. an evidence-based measure.

A. an outcome measure.

Which of the following is an example of a syndrome characterized by emotional exhaustion and a decrease in personal accomplishments that is directly associated with employment? A. burnout B. grit C. resilience D. failure to thrive

A. burnout

What type of organization recognizes and respects that information can come from any source within the organization and that each reporter has a valuable perspective? A. highly reliable B. diverse C. patient-centered D. interdisciplinary

A. highly reliable

An incident report relates that a nurse who completed a 12-hour shift on a newly opened ward forgot to document a skin assessment in the patient's medical record. This is an example of A. human error. B. careless action. C. at-risk behavior. D. recklessness.

A. human error.

Patient safety is considered a subset of quality, but it is more difficult to measure in part because A. identification of incidents often depends on self-reporting. B. caregivers are not held accountable to report incidents. C. incident reporting systems are always anonymous. D. of dependence on trigger tools to identify safety events.

A. identification of incidents often depends on self-reporting.

Results from recent tests were not included in a patient transfer from one facility to another, resulting in an adverse event. Which of the following is the most common cause of this type of harm? A. inadequate information flow B. inattentional blindness C. normalized deviance D. insufficient staffing

A. inadequate information flow

In process improvement, reducing variation improves A. predictability of outcomes. B. patient care processes. C. frequency of poor results. D. reluctance to simplify.

A. predictability of outcomes.

A patient safety professional receives an event report stating that a physician ordered anticoagulation medication to be discontinued through the physician order entry system. The pharmacy computer system did not receive the order, and the patient received four extra doses of the medication before the order was identified to be discontinued. The patient safety professional's investigation should focus on A. software interfaces. B. decision support. C. patient identification. D. business intelligence.

A. software interfaces.

An organization is implementing a standardized surgical safety checklist and encounters resistance from the perioperative staff. To improve staff engagement, a patient safety professional should: A. prepare a business case for the implementation of the checklist. B. present evidence that checklist use reduces practice variability. C. assure staff that anesthesia is responsible for the checklist. D. delegate checklist enforcement to nursing.

B. present evidence that checklist use reduces practice variability.

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 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 C. Control charts of overall infection rate by quarter for the past two years for each hospital in the region D. A table showing the number of CLABSI infections in each hospital in the region by quarter for the past two years

B. 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.

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. Apply best evidence with the goal of failure-free operation over time. C. Review annual data on defects and successes. D. Focus on a list of projects identified by senior stakeholders.

B. Apply best evidence with the goal of failure-free operation over time. In the IHI Framework for Safe, Reliable, and Effective Care, the role of patient safety specialists is to apply best evidence with the goal of failure-free operation over time. This involves reviewing data frequently (much more often than annually), designing systems to help people make the right choice (rather than relying on education to change behavior), and setting priorities in collaboration with senior stakeholders (rather than solely at their direction).

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

B. Develop a mechanism to gather input from a variety of sources. In order to understand the variety of safety issues that an organization faces, it is best to solicit concerns from a variety of sources. Focusing primarily on performance measurements or accreditation requirements will not identify or address the full range of possible priorities. Having information from a variety of sources will ensure all areas of importance are captured.

1. To improve culture of safety survey results, which of the following should an organization do? A. Offer coaching and apply Just Culture principles to leaders in lower performing areas. B. Examine high-performing units to identify and disseminate best practices. C. Perform root cause analysis on underperforming units to better understand their results. D. Acknowledge and celebrate high-performing areas in front of leadership.

B. Examine high-performing units to identify and disseminate best practices. Identifying bright spots and applying the learning to other settings is the best way to spread best practices. In regard to the other answer options: Applying Just Culture principles could be perceived as a punitive response to safety culture results; acknowledging high performers is important, but in isolation is unlikely to drive change in other areas; and, lastly, organizations most likely do not have the bandwidth to perform RCAs on underperforming units, and doing so would be a misuse of root cause analysis tools.

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

B. Executive leadership regularly participating in leadership rounds and daily safety briefings While all answers show a level of leadership commitment to safety, having executive leadership regularly participating in rounds and briefings is the best answer because it provides an opportunity for frontline staff to interact with senior leadership on a regular basis. In addition, by attending daily safety briefings, the senior leader stays engaged and aware of safety issues within the organization.

Which of the following is an example of a high reliability principle? A. individual accountability B. sensitivity to operations C. executive patient safety rounds D. adoption of cutting edge technology

B. sensitivity to operations

Which of the following is emphasized in crew resource management? A. care standards B. team leadership C. caregiver burnout D. health literacy

B. team leadership

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 process that pauses the surgery until all team members have participated in a timeout to confirm essential details of the surgery, including the correct side to operate on, is the highest reliability feature because it stops the process until safety checks have been performed. Training still relies on individual behavior to protect safety, which is not as reliable as a process that requires a timeout to proceed. Changing the color of the site marker does not ensure that the mark will be made on the correct side.

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 a culture of safety, staff members are free to report patient safety events, including close calls or near misses. Managers should have a non-punitive response to staff involved in errors and reward staff who report safety issues. Even though the error did not reach the patient or cause harm, it needs further investigation to identify any system failures, and to ensure that a process is in place to prevent an error from reaching the patient and causing harm.

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. Staff are not familiar with safety policies and protocols due to significant turnover. B. Leadership has stopped messaging on safety because significant time has passed since the last sentinel event. C. Negative changes in culture have reduced event reporting. D. Drift to old habits over time has slowly eroded safer practice.

B. Leadership has stopped messaging on safety because significant time has passed since the last sentinel event. The most likely explanation is that leadership has not maintained a strong enough focus on safety. With continued leadership attention on safety, drift to old habits should not be occurring, and staff turnover should not be impacting safety. (Note that safety policies and protocols are not safeguards against harm in and of themselves.) Sentinel events are typically significant enough that they would be noticed even in the absence of a strong reporting culture.v

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

B. Managing behavioral choices A Just Culture is a learning culture in which people learn from mistakes and/or potential mistakes. In a Just Culture, people look at all the factors that led to a harm event (or factors that may lead to harm), including behavioral choices, so that future harm can be prevented. Finding the individual to blame is incorrect because in a Just Culture, the focus is on system failures. Providing punishment equal to the severity of harm is incorrect because in a Just Culture, punishment is related to intent to do harm. Decreasing the amount of reported errors is incorrect because in a Just Culture, you would actually expect an increase of reported errors, especially related to near misses and/or great catches.

From a human factors engineering perspective, which of the following should beknown about identifying and eliminating diagnostic errors? A. Diagnostic errors are the result of cognitive biases and failures by clinicians. B. Partnership with scientists in cognition, perception, and decision making is needed. C. An effective strategy to reduce diagnostic errors is the use of checklists. D. Attribution of diagnostic errors is not subject to either hindsight or outcome biases.

B. Partnership with scientists in cognition, perception, and decision making is needed.

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

B. Patient and family engagement, health literacy, and transitions in care Patient 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.

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. Hold a root cause analysis. B. Perform the substitution test with three other nurses. C. Ask other nurses if the staff nurse is trustworthy. D. Have the chief nursing officer interview the nurse.

B. Perform the substitution test with three other nurses. Performing the substitution test, which entails asking other professionals if they would be likely to repeat the same behavior if placed in the same situation, is an effective way to assess whether a blameworthy event has occurred. In this case, if other individuals say they might have also skipped the double-check, it is fair to assume there is an underlying systems issue at fault for the nurse's actions, and she should not be held personally accountable. The other options listed are not reasonable methods to discern whether the problem is a systems issue or a blameworthy personnel issue.

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. Effectively modifying behavior and developing acceptance of workplace changes requires a multifaceted approach, and storytelling and quantitative analysis are important aspects of effective calls to action. Some experts suggest that more than one method of communication is necessary to be truly effective. The other answers represent actions that could be taken depending on the specific issue; however, providing a motivational story and your own facility's data would likely be most effective in this scenario.

1. 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. An electronic reporting system B. Psychological safety C. Situational awareness training D. Training on reporting

B. Psychological safety In this case, regardless of whether the nurse has the knowledge or ability to report the error, he is not speaking up because he does not feel psychologically safe to do so. If the nurse felt psychologically safe, he would feel confident that his concern would be heard and that appropriate, system-focused action (as opposed to misplaced blame and punishment) would ensue.

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

B. The event should be openly discussed with the patient, family, and staff. Patients have a fundamental right to know what happened when an adverse event occurs. Disclosure will build a relationship of trust and facilitate the identification of improvements. Evidence does not suggest that disclosure increases malpractice costs. The Joint Commission does not require submission of a root cause analysis. Staff members are "second victims" and usually should be supported and not blamed when an adverse events occurs.

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

B. Transparency The Lucian Leape Institute defines transparency as the free, uninhibited flow of information that is open to the scrutiny of others. The other three options would not be so defined.

Which of the following strategies is best for facilitating the acceptance of changer elated to specific performance improvement initiatives? A. Provide a quarterly statistical report. B. Utilize storytelling tools. C. Recognize leadership participation. D. Distribute weekly newsletters via e-mail.

B. Utilize storytelling tools.

A practitioner reads a groundbreaking study on a condition seen frequently in their practice. Coincidentally, the next patient that the practitioner sees has symptoms commonly seen with that condition. Which of the following biases or heuristics best describes this phenomena? A. anchoring B. availability C. premature closure D. risk aversion

B. availability

A healthcare organization is introducing a new medication administration barcoding system. Which of the following is the most significant indicator of successful implementation? A. order accuracy for high-risk medications B. bar code scanning compliance C. nursing bar coding knowledge D. bar coding performance goal setting

B. bar code scanning compliance

Which of the following would best demonstrate non-random process variation over time? A. histogram B. control chart C. run chart D. pie chart

B. control chart

After implementing a new product recall system, a hospital was alerted to a high-risk medication recall. This medication is in stock in the emergency department and oncology unit. To ensure the effectiveness of the new system, a patient safety professional should: A. require individual departments to verify that a search for the recalled medication was performed. B. ensure an on-site visit verifies that the recalled medication was sequestered. C. reconcile the number of doses administered to the number of doses purchased. D. notify the affected units via fax to remove recalled meds and to post recall notices in the units

B. ensure an on-site visit verifies that the recalled medication was sequestered.

A patient who is a heroin addict and frequent visitor to the emergency department presented to the hospital with abdominal pain, nausea, and vomiting. He was admitted for dehydration and potential opioid withdrawal. The patient's abdominal pain worsened at night, prompting the nurse to call the physician on call. The physician assumed that the patient was drug-seeking, and increased the patient's methadone. Early the next morning, the patient experienced severe abdominal pain, showed signs of sepsis, and was found to have an abdominal perforation. Which cognitive process best describes the on-call physician's response? A. hindsight bias B. implicit bias C. normalization of the deviant D. recall bias

B. implicit bias

When healthcare providers are involved in an adverse event, it is important to first A. conduct an objective root cause analysis. B. offer guidance and emotional support. C. involve crisis counselors in the investigation. D. consult providers who experienced a similar event.

B. offer guidance and emotional support.

While investigating a near miss medication event, a manager identifies a pattern of work arounds by a clinician that violates policies and procedures. To determine accountability, the manager's next step should be to A. conduct a focus group with work area staff. B. perform a substitution test. C. escalate the workarounds to leadership. D. amend procedures to support the workarounds.

B. perform a substitution test.

A physician is planning to discharge a patient. The nurse knew that the patient needed additional equipment at home. Together they reached out to the social worker and discharge planner for a safe care transition. Which feature of the culture of safety did they practice? A. activation of transfer protocols B. utilization of open communication C. measurement of patient safety D. ensuring health literacy

B. utilization of open communication

A patient safety professional is leading a process improvement team to enhance communication hand-offs between hospital units. Which of the following is the best question to ask at the first team meeting? A. "What process change should be the focus?" B. "When should direct observations begin?" C. "What are we trying to accomplish?" D. "When should we spread best practices?"

C. "What are we trying to accomplish?"

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. 0% 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. The percent positive score refers to answers that reflect the presence of patient safety. In this case, the question is asking about a risk to patient safety, so the responses of "agree" and "strongly agree" are negative responses for patient safety. The percent positive score of 30% means that 30% of the staff disagreed with this statement, thereby saying that patient safety is present.

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 is accurate when a patient has back-to-back procedures, and the person performing each procedure changes? A. No staff changes may occur between procedures. B. One time-out at the beginning of the first surgery is sufficient for each procedure. C. Another time-out needs to be performed before starting each procedure. D. No additional sponge count is needed between surgeries.

C. Another time-out needs to be performed before starting each procedure.

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. Request that the pharmacy run a report of the BCMA compliance rates of the unit. B. Ask staff if there are adequate scanners to meet their needs. C. Ask the nurse what was occurring at the time, and why she chose to bypass the policy. D. Counsel the nurse on the importance of following policy.

C. Ask the nurse what was occurring at the time and why she chose to bypass the policy. In determining the appropriate response to a violation of policy, it is important to learn what the incentive was for the behavior and what conditions led the staff member to their action. The Just Culture algorithm can serve as a guide. In this case, it is important to understand the nurse's rationale for diverting from the policy. For example, did she think the benefit outweighed the risk for some reason?

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. Offer to do a claims analysis for any related errors. B. Suggest a Plan-Do-Study-Act (PDSA) cycle. 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). 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.

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

C. Conduct an assessment and gather focused data. As a first step in improving the culture, an assessment and data review are necessary to determine the current strengths and weaknesses of the organization. Once strengths and weaknesses are identified, then focused action plans can be developed for improvement. (New policies and procedures and/or communication and teamwork tools could be part of the action plans). Having a patient safety officer is important but not as central to the improvement effort as the data.

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. Develop a "Request for Proposal" to submit to various software vendors. Evaluate the best responses to make a recommendation. C. Conduct an open vendor fair for all staff to review various options. Evaluate written and verbal feedback on the systems from participants. D. Survey your peers across the nation to determine the most popular vendor. Recommend the vendor that is referenced most frequently.

C. Conduct an open vendor fair for all staff to review various options. Evaluate written and verbal feedback on the systems from participants. The most successful and sustainable changes to organizational structure are developed through a grassroots approach to leadership and workflow design. This has been demonstrated with multiple workplace changes, but particularly with the implementation of new reporting systems.With regard to the other possible answers: Senior leaders should be involved with the decision-making process but should not necessarily provide exclusive input on the decision. The "Request for Proposal" may be an important part of an organization's evaluation process but should not be the sole input into the recommendation process. Finally, conducting benchmark evaluations can be helpful, but the simple tally described is too simplistic to determine a software recommendation.

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

C. Fail-safes Fail-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.

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. Root cause analysis (RCA) B. Patient safety leadership WalkRounds C. Failure modes and effects analysis (FMEA) D. Meaningful use evaluation

C. 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.

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

C. 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.

As a member of an improvement team focused on standardizing surgical protocols, the patient safety professional recognizes that one concern clinicians may raise is: A. improved supply chain management. B. increased amount of waste. C. depersonalized care. D. increased length of stay.

C. depersonalized care.

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. Ask Information Systems to either fix the old system or build a new one. B. Purchase the least expensive software. C. Identify key stakeholders and perform a gap analysis of current state to ideal state. D. Poll colleagues and purchase what they use.

C. 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.

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. With an anticipated ROI greater than 100 percent, reducing catheter-associated urinary tract infections is most likely to receive the CFO's approval based on the ROI alone.

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

C. 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 The first answer (sending human resources all event data so that they can record involvement in adverse events in personnel files) is incorrect because including all events in personnel files regardless of blame worthiness does not support a just culture. The second answer (including human resources in all root cause analyses so that they can provide guidance on recommended training updates for staff) is interesting but incorrect because recommendations for staff training could come out of the RCA process without the involvement of HR. The third answer (implementing routine use of a tool to determine which events are attributed to human error, at-risk behavior, and reckless behavior) is not correct because, while it makes the good suggestion of using a tool to distinguish among human error, at-risk behavior, and reckless behavior, it does not address what to do with that information; human resources should be consulted to help determine fair consequences for blameworthy events — this makes the fourth answer the best.

The patient safety professional disseminated a patient safety culture survey to all employees at a 100-bed hospital. The total response rate was 32%. Which of the following should the patient safety professional do next? A. Re-survey the staff to obtain a higher response rate. B. Form a task force to address the questions on the safety survey. C. Interpret the results with caution due to the response rate. D. Contact the managers of the units to identify non-responders.

C. Interpret the results with caution due to the response rate.

In the context of failure modes and effects analysis (FMEA), how is the risk priority number (RPN) used? A. It prioritizes the failure modes that do not require action. 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 calculates the failure modes that will create the most errors

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.

From a human factors standpoint, which of the following is true about harmduring healthcare? A. It is either due to system errors or intentional human choice. B. It would not occur if healthcare workers followed rules. C. It is prevented by healthcare workers adapting to changes. D. It is always preventable; the goal is zero harm.

C. It is prevented by healthcare workers adapting to changes.

In preparation for new antimicrobial stewardship regulatory requirements, a hospital is creating an antimicrobial stewardship committee. What should be the first step in supporting this new patient safety initiative? A. Reach out to subject matter experts to gain insight on different compliance issues. B. Work with information technology (IT) to build antibiotic indication and time-out screens. C. Partner with key stakeholders to perform a gap analysis of current state to ideal state. D. Review the past year's data to identify the most commonly grown pathogens.

C. Partner with key stakeholders to perform a gap analysis of current state to ideal state.

Which of the following actions provides evidence that a healthcare organization considers patients' experiences to improve the safety of patientcare? A. Consumers, payors, and administrators are represented on committees. B. Patients receive experience surveys after reviewing charges. C. Patient feedback is used to redesign care processes. D. Patient involvement is publicly recognized.

C. Patient feedback is used to redesign care processes.

Which of the following is most important in building a culture of safety? A. measuring safety outcomes B. addressing burnout C. establishing shared values D. utilizing electronic health records

C. establishing shared values

Which of the following types of errors is due to a previous management decision that impacted design, resulting in patient harm? A. active error B. commission error C. latent error D. omission error

C. latent error

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. Lead an open discussion of board members' safety concerns and recommendations. B. Display a graph of the numbers and types of safety events reported in the past year. C. Present cases of harm with contributing root causes and actions taken. D. Highlight system-wide improvements that have been implemented in the past year.

C. Present cases of harm with contributing root causes and actions taken. The board of trustees maintains ultimate responsibility for the quality and safety of care provided. It is important that the board be aware of the harm that occurs within the facility, the systemic issues that may have caused or contributed to that harm, and the actions taken to prevent or mitigate the risk of harm.

Which of the following statements about root cause analysis (RCA) is accurate? A. The goal of performing an RCA is to find the one underlying root cause. B. RCAs are not subject to outcome or hindsight biases. C. RCAs may be subject to political highjack, resulting in poor risk controls. D. RCAs are as effective in healthcare as they are in other high-risk industries.

C. RCAs may be subject to political highjack, resulting in poor risk controls.

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. Gather data about the frequency and content of the WalkRounds to establish current baseline performance. B. Review information boards in the areas included in the WalkRounds to determine the scope of issues raised. C. Survey staff and leaders about their views on patient safety WalkRounds. D. Discuss the informal feedback you have been receiving with the CEO.

C. Survey staff and leaders about their views on patient safety WalkRounds. The concern that is being voiced informally needs validation through formal data collection. Surveying a reasonable sample of staff and leaders about WalkRounds would create a valid data perspective on the deployment and impact of WalkRounds that could be used by the patient safety professional to refine the deployment strategy.Reviewing information boards and discussing the informal feedback could add to the informal understanding of what is occurring with WalkRounds but is not comprehensive enough to establish an objective assessment of the situation. Gathering data about only the frequency and content of the WalkRounds will not provide a comprehensive, data-driven answer to the deployment effectiveness but questions about these topics should be included in the survey.

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. Although a one-time event, the missing biopsy samples are the strongest contender for RCA because the problem may result in very significant harm (e.g., if there is no option for additional biopsy and a diagnosis cannot be made) and because the situation clearly represents deviation from practice standards, in this case related to chain of custody of a specimen. An RCA would identify the potential for this to happen again and define actions to close the gaps in the management of specimens. A possible contender for RCA is the fact that there have recently been three occurrences of depressed respirations related to sedation in the same department. Although a single event of this type would probably not trigger RCA because of the inherent risk of invasive procedures, the pattern of events seems to warrant some kind of investigation. The group of events need to be analyzed, such as by peer review, to look for common causes and assess the best course of action, including whether to proceed with RCA.

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. Re-educate the OR nursing staff on keeping track of instruments on the sterile field. B. Revise the hospital policy to make it clear that surgeons must stay in the operating room (OR) until instrument count issues are resolved. C. Using an appropriate accountability system, counsel the surgeon about customary clinical standards. D. Create a process map of how instruments are managed during surgery, looking for latent flaws.

C. Using an appropriate accountability system, counsel the surgeon about customary clinical standards. The surgeon made a choice to leave for personal reasons before receiving confirmation that his patient was safe. In the substitution test, other surgeons would likely consider it their responsibility to stay and assure the patient was object-free.Although the policy could clearly outline that a surgeon must stay until counts are confirmed, it is unrealistic for leaders to regulate every step of every process and practice: As health care professionals, surgeons already have a pre-existing, overarching duty to avoid causing unjustifiable risk or harm. In this case, counseling the surgeon likely does not mean pulling his privileges; it means having a conversation with him about the inappropriateness of the action he took and the potential impact on his patient. Sometimes individuals do share the responsibility for a deviation, and we need to hold professionals accountable for their portion of a situation even when system factors may also need improvement.

Which of the following is the most appropriate method to determine if a root cause analysis (RCA) should be conducted on an adverse event? A. Consider only the outcome severity. B. Consider only blameworthy events. C. Utilize a risk-based prioritization system. D. Assess only the probability of recurrence.

C. Utilize a risk-based prioritization system.

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. Revise the process to allow only one specimen label on the nurse/phlebotomist tray at a time. B. Educate all nurses and phlebotomists to ask about patient identifiers before obtaining specimen. C. Utilize barcode scanners to generate a specimen label at the bedside. D. Standardize the process to require the nurse/phlebotomist to ask the patient to state their name prior to the specimen collection.

C. Utilize barcode scanners to generate a specimen label at the bedside. 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.

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 What is the Percent Positive Score that should be reported for this item?

Correct Answer: 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%.

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

D. Accountability must be universal and reciprocal, not just top-down. A just culture maintains standards of universal and reciprocal accountability. A just culture also favors patient-centered (as opposed to provider-centered) care; encourages interdependency, collaboration, and inter-professional teamwork; and believes that the causes of most errors can be traced to system failures.

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. Take on the nurse's patients for the rest of the shift. B. Reassign the nurse's patients to the most senior nurse on the unit. C. See if this is an established pattern for this nurse. D. Call a huddle to reassign resources and establish a contingency plan.

D. Call a huddle to reassign resources and establish a contingency plan. The best answer is to call a huddle, which is an appropriate option for ad hoc planning. During the huddle, the team can reestablish situational awareness, confirm the plans already in place, and assess the need to adjust the plan.An established pattern of absenteeism is more of an HR issue than a patient safety issue. The pros and cons of the other options, including the charge nurse taking on the patients (which would leave the team without a leader) or the most senior nurse (who may already have the most patients) taking on extra patient patients, can be discussed at the huddle.

When interpreting data after a safety event, which of the following is true? A. Identifying human error results in a deep understanding of the event and its causes. B. Comparing actions taken to procedures and rules will explain the behaviors during the event. C. The outcome of the event has no influence on the interpretation or conclusions. D. Causes are constructed from the investigation and analysis.

D. Causes are constructed from the investigation and analysis.

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. Root cause analysis (RCA) B. Plan-Do-Study-Act (PDSA) C. Define, Measure, Analyze, Improve, and Control (DMAIC) D. Failure modes and effects analysis (FMEA)

D. 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.

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

D. Help scope the objectives and maintain accountability for effective and timely action plans. Completing the initial debrief describes the role of the department manager or leader. Preparing for a visit by the department of health is the responsibility of the regulatory staff, and coordinating all efforts of the cause analysis team speaks to responsibilities of the cause analysis facilitator and department manager. The Executive Sponsor can help establish the team charter, ensure adequate resources, and attend cause analysis meetings as appropriate.

A new long-term care facility is being planned. Recognizing that resident injuries related to falls are a significant concern, a team has been convened to plan, implement, and evaluate potential solutions. Which of the following interventions will have the largest impact on the rate of injuries related to falls? A. Position grab bars in bathrooms. B. Attach egress alarms to residents. C. Locate floor pads next to beds. D. Install impact-absorbing flooring.

D. Install impact-absorbing flooring.

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

D. 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.

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. The most important reason for staff to report safety events is because they believe the information will be used to make care safer. If leaders do not provide feedback and follow-up about what is being done in response to an event report, staff are unlikely to continue to report, even if other incentives are in place.

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. How many years the individual has been practicing B. Whether the individual filed a claim with risk management C. The individual's most recent performance review D. The contribution of systems factors on the individual's behavior

D. The contribution of systems 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 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 detectability decreased and RPNs were lower. B. The frequency numbers increased and RPNs were lower. C. The frequency numbers decreased and RPNs were higher. D. The detectability increased and RPNs were lower.

D. 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.

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. It is reviewed and signed by a patient safety professional. B. Corrective actions have been developed and completed. C. A single, clearly defined root cause has been identified. D. There is participation by leadership and individuals closely involved in the process.

D. 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).

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

D. Use staff recommendations for workflow. Using staff recommendations for workflow improves employee engagement by providing a sense of ownership over the initiative. Communicating the purpose of the initiative to the governing board enhances leadership support and commitment, not employee engagement.

Leadership has been promoting fair and just culture concepts including non-punitive response to reporting and the value of near miss reporting. The plan is not universally supported, and some argue it is a waste of the facility's resources. To support this leadership initiative, a patient safety professional should explain that the plan is intended to result in A. a decrease in event reporting volume due to fewer actual adverse events. B. a decrease in event reporting due to fewer near misses. C. an increase in event reporting that will decrease malpractice insurance premiums. D. an increase in event reporting that will help the hospital identify areas of risk.

D. an increase in event reporting that will help the hospital identify areas of risk.

Despite pre-procedure screening for scheduled MRIs, patients with implanted devices presented for scheduled MRI procedures. Technicians identified the hazards and prevented patients from entering the suite. The most effective action for the patient safety professional is to recommend A. using track and trend reports for repeat occurrences. B. suspending provider MRI ordering privileges for repetitive noncompliance. C. requiring providers and staff to complete a safety training program. D. collaborating with providers and staff to strengthen the screening process.

D. collaborating with providers and staff to strengthen the screening process.

When processing an order for diagnostic imaging of a patient's left foot, the nurse remembered changing the dressing on the right foot. The nurse called the provider to confirm the laterality, and the order was corrected. Which critical feature of the culture of safety did the nurse practice? A. measurement of patient safety B. ensuring all orders are carried out C. awareness of health education D. detection of a near miss

D. detection of a near miss

On studying the results of a root cause analysis, it is recognized that an RN missed steps in a protocol. The RN is regarded as highly competent by colleagues and unit leaders. The patient safety professional should determine the RN's behavior in this error to be considered A. workaround. B. reckless. C. high risk. D. drift.

D. drift.

An organization has achieved 92% compliance with a process measure. The patient safety professional believes that the processes in place are not reliable or that the results are attributable to luck. Which of the following best describes this characteristic? A. appreciative inquiry B. commitment to resilience C. deference to expertise D. preoccupation with failure

D. preoccupation with failure

A just culture framework provides a means to address behaviors that undermine a culture of safety because A. single outbursts are differentiated from consciously chosen acts. B. preservation of highly valued team members is a primary goal. C. the evaluative process does not consider personal performance-shaping factors. D. the organizational response to investigated events is independent of patient outcome.

D. the organizational response to investigated events is independent of patient outcome.

When evaluating the conduct of a healthcare worker in the aftermath of a harm event, which of the following considerations demonstrate consistency with the principles of a fair and just culture? A. the severity of the injury that occurred B. alignment with state health department regulations C. the impact to the organization's reputation D. the practice of similarly qualified individuals

D. the practice of similarly qualified individuals

When creating action plans, which of the following solutions would be considered the weakest? A. visible involvement and action by leadership B. standardizing processes as much as possible C. creating access barriers to high-risk medications D. use of color-coded labels that are readily seen by staff

D. use of color-coded labels that are readily seen by staff