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Our most recent data reveal that, on average, we reconcile the medications of only 35 percent of our discharged inpatients. We intend to increase this average system-wide to 50 percent by April 1, 2017, and to 75 percent by August, 31, 2017. (A) Strong (B) Weak

(A) Strong

Which of the following traits do histograms, Pareto charts, and scatter plots have in common? (A) They are all bar charts. (B) They are all visual tools to display data. (C) They all show change over time. (D) All of the above.

(B) They are all visual tools to display data.

We aim to reduce harm and improve patient safety for all of our internal and external customers. (A) Strong (B) Weak

(B) Weak

You should never end a test of change before the planned time. (A) True (B) False

(B) False

Some types of actions tend to be weaker and other actions tend to be stronger, regardless of context. Let's take a look at a few possible actions below. Is the action relatively strong, intermediate, or weak? Add a checklist for a surgical procedure. (A) Strong (B) Intermediate (C) Weak

(B) Intermediate Checklists are only effective if they are used - and if the items on the checklist really have a strong connection to patient safety.

We will reduce all types of hospital-acquired infections. (A) Strong (B) Weak

(B) Weak

Which of the following types of interventions is likely to be most effective for improving safety? (A) Increasing staffing (B) Conducting additional training (C) Posting warning signs (D) Standardizing processes

(D) Standardizing processes The best answer is standardizing processes. All of these types of interventions can help improve safety, but things like adding staff, trainings, or signs are not usually as effective as truly changing the process.

Some types of actions tend to be weaker and other actions tend to be stronger, regardless of context. Let's take a look at a few possible actions below. Is the action relatively strong, intermediate, or weak? Redesign the crash cart or supply room to keep easily confused drugs apart. (A) Strong (B) Intermediate (C) Weak

(A) Strong Changing the physical environment in which people work has a longer-lasting impact than giving instructions to one group of staff members.

An aim statement should include the following: (A) Specific time frame, team membership, and numeric goals (B) Numeric goals, specific time frame, and the patient population or system affected (C) Patient population or system affected, estimated cost of improvement, and numeric goals (D) All of the above

(B) Numeric goals, specific time frame, and the patient population or system affected

Linda, a pharmacist at an outpatient pharmacy for a medium-sized medical group, receives a call from John, a nurse practitioner in the cardiology clinic. John tells Linda he needs to call in a new prescription for hydrochlorothiazide at 50 mg once a day for Ms. Krane. At the end of the conversation Linda says to John, "Okay, so you want Ms. Joanne Krane to have a new prescription for hydrochlorothiazide at 50 mg by mouth once a day. Thirty pills and six refills." What has Linda just done? (A) Increased the likelihood of error by repeating an order (B) Provided a read back (C) Used SBAR in communication (D) B and C

(B) Provided a read back This is a read back, which is used to confirm receipt of information (SBAR is a system for delivering information). The pharmacist went through the step of verbally verifying the order from the nurse practitioner by repeating it back to him, which can catch mistakes. The additional time that a read back requires is not a waste. In fact, it may make work more efficient by decreasing the need for later calls for clarification.

Which of the following is a support mechanism that might be available to caregivers after traumatic events? (A) Care coordination (B) The Employee Assistance Program (C) Ombudsmen (D) The patient relations department

(B) The Employee Assistance Program A variety of support systems may be available to the caregivers involved in a medical error, including the Employee Assistance Program (EAP), psychological counseling, the local medical society, or organizations such as Medically Induced Trauma Support Services.

After shadowing, which of the following should you include in your shadowing report? (A) First and last names of the patients and family members who were involved (B) Your ideas for improvement (C) First and last names of the caregivers who were involved (D) Both A and C

(B) Your ideas for improvement As the shadower, you should include your ideas for improvement. To protect the identities of those involved, shadowing reports should not include the names of the people whom you observed during shadowing.

What is a culture of safety? (A) A place where errors never happen (B) A place where errors are always caught (C) A place where all staff can talk freely about safety problems without fear (D) A place where all staff feel comfortable reporting errors only if they're guaranteed anonymity

(C) A place where all staff can talk freely about safety problems without fear Humans, even humans using technology, are fallible. In health care, there will always be errors and near-misses. In a culture of safety, however, people feel comfortable discussing errors and are rewarded for their focus on patient safety. Although an anonymous reporting system may be useful, the fact that it needs to be anonymous may indicate that people don't feel comfortable discussing errors openly.

Aim: Reduce the average waiting time in the emergency department (ED) to 30 minutes by next August. Percentage of staff reporting they're satisfied at work and total ED staffing costs (A) Outcome measures (B) Process measures (C) Balancing measures

Effective health care teams have several important characteristics, including: (A) The ability to rehearse procedures together, like a choir or a sports team. (B) Stable membership; that is, they have the same people on the team from day-to-day. (C) Effective communication techniques. (D) The ability to achieve good results without strong communication.

(C) Effective communication techniques. Effective health care teams have a shared goal and effective two-way communication. The membership of the team may change frequently (Answer B), and it's quite possible for a health care team to consist of people who have never worked together before (Answer A). That makes strong, two-way communication a critical part of delivering safe care.

The radiology department you work in has had an unusual number of errors in the past year. Specifically, several patients have undergone procedures entirely different from the ones ordered. Unfortunately, the department does not have a culture of safety, and open discussion of mistakes is almost unheard of. During the course of the improvement project in the radiology department, it becomes clear that certain radiology technicians suspected that patients were about to undergo the wrong procedures, but they did not speak up. Which of the following changes is likely to be low-cost, quick to implement, AND effective? (A) Change the forms patients use to check in for their procedures. (B) Implement an electronic health record. (C) Implement standardized procedures to help enable workers to speak up. (D) Adjust the schedule so that certain procedures are only done at a particular time each day.

(C) Implement standardized procedures to help enable workers to speak up. The best answer is helping to provide a standard way for anyone in the group to speak up when something may be going wrong. Although the other options may help, they are likely to be slower to implement and in some cases (e.g., Answer B) quite costly.

According to researchers, which of the following is a common reason why caregivers choose not to communicate when something bad happens? (A) They feel the harm is not their fault. (B) They lack empathy for patients and families. (C) They fear disapproval. (D) All of the above

(C) They fear disapproval. In the paper discussed in this lesson, published by Banja and colleagues, there were many reasons why providers found it challenging to communicate with patients and families after adverse events, many of which related to fear — fear of disapproval, fear of job loss, fear of anger from the patient, fear of lawsuits, etc. Providers did not discuss lacking empathy for patients and families or feeling that the harm was not their fault.

Which of the following BEST describes the purpose of a histogram? (A) To show the relationship between two variables (B) To show variation in weight over time (C) To show distribution of continuous data (D) None of the above

According to Paul Levy, which of the following were factors that led to the wrong-site surgery at Beth Israel Deaconess Medical Center in June 2008? (A) The surgical team did not properly follow a "time out" procedure. (B) There were systemic problems in the hospital. (C) The surgical team marked the wrong site on the patient. (D) A and B

(D) A and B The best answer is A and B. According to Levy, multiple factors led to the wrong-site surgery (which occurred even though the surgical team marked the correct site), one of which was that the team did not conduct a "time out" safety check, another of which was a broader systems issue, in that the hospital did not have adequate mechanisms in place to prevent such an error in an extremely hectic operating room environment.

When teams communicate poorly in health care, consequences can sometimes include: (A) Providing care with incomplete or missing information (B) Confusion during transitions in care (C) Team members not speaking up about their concerns (D) All of the above

(D) All of the above All of the above choices are some of the potential consequences of poor communication. When health care teams do not communicate effectively, bad things can happen.

Janice is a nurse on the orthopedics unit. This night, she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later, she realizes, to her dismay, that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, "Why won't someone help me?" Janice quickly administers the morphine. When discussing the event with Mrs. Bernardo, the most appropriate initial comment would be: (A) "How is your pain?" (B) "Although it took an hour to get the pain medication, we remain committed to making sure you receive excellent care." (C) "I apologize for the delay in your morphine." (D) "Pain medication can be very tricky, so we are always careful not to give too much, too quickly. Sometimes that means that it takes a while to get your pain under control."

(A) "How is your pain?" The first and most important issue when a patient receives less than ideal care is to make sure you stabilize and care for the patient. Only after the patient's safety and comfort are addressed should you consider an apology.

What is "SBAR"? (A) A system for delivering information (B) A system for identifying areas for improvement (C) A system for confirming receipt of information (D) A system for assessing patient values

(A) A system for delivering information SBAR, which stands for "Situation-Background-Assessment-Recommendation," is a system for delivering information. It is an adaptation of a US Navy communication technique and can be an effective means to communicate urgent patient care issues.

Shadowing can help you to: (A) Reveal inefficiencies and redundancies. (B) Secretly spy on caregivers whom you suspect to be negligent. (C) Collect patients' personal health information for research purposes. (D) All of the above

(A) Reveal inefficiencies and redundancies. The correct answer is that shadowing can help you to reveal inefficiencies and redundancies in the care process. It can also help you to feel a renewed sense of empathy and create the urgency to drive change. Shadowing is done openly: It is not a "secret shopper" program. Shadowers do not collect patients' personal health information for any purpose.

You and your team should reflect on the results of every change. (A) True (B) False

(A) True

As the Health Unit Coordinator (HUC), it is your job to enter orders from providers into the computer system. Direct provider order entry is planned for your hospital next year when the electronic health record is implemented. You check charts every couple of hours for new orders, unless the providers "flag" the chart by turning a dial on its side to red — in which case, you check the chart right away. On a particularly busy day, you see a chart tucked in a corner and realize that you have not looked at it in at least six hours. Worse, you check the order dial and see that it's partly red. On the order sheet are orders for "STAT" pain medications and antibiotics for a new patient. You quickly input the orders, your heart pounding. Three hours later, the patient is transferred to the intensive care unit with worsening sepsis (infection). Based on what you know about the incident, which of the following statements seems to be a fundamental attribution error? (A) "Someone almost died because things were so busy yesterday." (B) "The HUC almost killed someone yesterday because she doesn't pay enough attention." (C) "The electronic health record can't come soon enough — the current system almost killed someone yesterday." (D) "I can't believe what an awful situation the HUC ended up in yesterday; someone almost died."

(B) "The HUC almost killed someone yesterday because she doesn't pay enough attention." Three of these statements attribute the error to external factors; however, saying "The HUC almost killed someone yesterday because she doesn't pay enough attention," assumes the error occurred as a result of your internal makeup (i.e., you don't pay enough attention), and is likely a fundamental attribution error. According to the theory of fundamental attribution error, our human tendency is to assume, wrongly, that people's behavior is a reflection of their personal qualities rather than of the situation in which they find themselves.

What is the minimum number of data points you should usually have to look for signs of improvement on a run chart? (A) 6 (B) 10 (C) 15 (D) 25

(B) 10 A run chart becomes more powerful as you add more data points because there will be more opportunities to identify patterns. If you're looking for signs of improvement, usually you need at least 10 data points.

When testing changes, you should be sure to gain consensus and buy-in from all the people who would eventually be affected by the change. (A) True (B) False

(B) False

With regard to requesting permission to shadow, which of the following statements is true: (A) Written permission is always required. (B) If the patient denies permission, you should thank them. (C) You should expect most patients will say "no." (D) All of the above

(B) If the patient denies permission, you should thank them. Whenever you ask for permission to shadow, you should always thank the patient or family member, even if they would prefer not to participate. In most cases, however, patients are willing to be shadowed. You must ask for and obtain permission, but in some cases verbal consent may be adequate. Check with your organization or legal team before you get started.

The orthopedic clinic plans the change to improve scheduling, and then it carries out a small test of change with three patients on Tuesday morning. What's the next thing the clinic's improvement team should do? (A) Change their measures. (B) Measure to see if the change led to improvement. (C) Report their results to the clinic leadership and prepare a poster for a national meeting. (D) Implement the new scheduling process based upon their initial impressions of how everything is working.

(B) Measure to see if the change led to improvement.

Which of the following is likely to be the most immediate result of building an effective health care team? (A) Less costly health care (B) Safer care (C) Fewer delays in care (D) Elimination of waste in the system

(B) Safer care The best answer is that care will be safer. For example, according to The Joint Commission, an estimated 80 percent of serious medical errors can be linked to miscommunication between caregivers when patients are transferred or "handed-over." One of the hallmarks of effective health care teams is frequent, two-way communication — a characteristic that would likely have an immediate and positive effect on care transitions and safety. While better teamwork can lead to fewer delays, elimination of waste, and even less costly care, these results would likely be secondary to an increase in safety.

You're on a team seeking to improve the process for treating patients with sepsis. (Sepsis occurs when chemicals released into the bloodstream to fight infection trigger inflammatory responses throughout the body). Which of the following is an example of "advocacy"? (A) Listening to your teammate's idea to improve screening for sepsis. (B) Stating your idea for updating the sepsis protocol. (C) Adapting your idea for the sepsis protocol based on your teammate's input. (D) A and C

(B) Stating your idea for updating the sepsis protocol. The best answer is stating your idea for updating the sepsis protocol. Advocacy is making your own views known (including why you feel or think the way you do). Inquiry is seeking the views of others. The key to being an effective team member is balancing advocacy and inquiry.

Which of the following scenarios would call for a root cause analysis? (A) An occupational therapist quits after only three days on the job. (B) A physician is convinced that there is a better way to deliver pain medications on her unit. (C) A social worker catches a patient who is falling out of bed. (D) An administrator needs to develop a balanced budget.

(C) A social worker catches a patient who is falling out of bed. RCAs can be very useful in health care to address both errors as well as near misses, such as the near-fall in answer choice C.

Your nursing home has had some serious pressure ulcers during the past month. As one of the medical leaders, you know this problem needs to be tackled. However, you have also taken on a couple of other projects and you are feeling overwhelmed. What might be the most reasonable plan for you to enact moving forward? (A) Wait until next quarter to start the project; you should have more time then. (B) Ask your assistant Medical Director to begin work on decreasing these rates right away. (C) Organize a small meeting of stakeholders to present this issue to leadership and begin the work together. (D) Double-check the charts of patients with the serious ulcers to see if one nurse is to blame for the problem.

(C) Organize a small meeting of stakeholders to present this issue to leadership and begin the work together. Leadership must be active and visible supporters of improvement and safety efforts. Delegating these tasks sends the message that this work is not as important as other efforts. Waiting will not likely remove the problem; likewise, a culture of blame is not helpful for anyone.

Effective team leaders: (A) Have multiple degrees. (B) Are usually physicians. (C) Seek input from all members of the team. (D) Know the correct answer in any given situation.

(C) Seek input from all members of the team. Effective team leaders are not necessarily the ones with the most training, the most degrees, or the highest salary. And they don't always have all the answers. They do, however, seek feedback from all team members, recognizing that one person can't provide safe care alone.

Some types of actions tend to be weaker and other actions tend to be stronger, regardless of context. Let's take a look at a few possible actions below. Is the action relatively strong, intermediate, or weak? Train staff in IV pump use. (A) Strong (B) Intermediate (C) Weak

(C) Weak Training, while beneficial, only impacts staff members who participate. People can also forget their training and revert back to old ways of doing things, so as a recommended action, this may be a bit weak.

You're a public health student, and you're interested in learning more about what the patient experience is like at a local clinic. Before you begin shadowing, you should consult with the clinical leaders in the care experience you plan to shadow to: (A) Obtain permission, including any clearances needed to shadow in the facility. (B) Assure that caregivers throughout the care experience are informed. (C) Make arrangements to report your findings. (D) All of the above

(D) All of the above The best answer is all of the above. Before you begin shadowing, you will need to consult with the clinical leaders in the care experience to obtain permission, including any clearances needed to shadow in the facility; assure that caregivers throughout the care experience are informed; and, importantly, make arrangements to report your findings.

What aspect of the run chart helps you compare data before and after a PDSA cycle? (A) The average of the values (B) The baseline median (C) Annotations of when specific changes were tested (PDSA cycles) (D) B and C

(D) B and C

As you recall, the IHI staff member's change idea involves leaving work by 5:30 PM each workday. Which of the following is an example of using technology to help her do so? (A) Comparing the time she leaves to that of the person who seems to go home earliest each day. (B) Cancelling two meetings every day. (C) Scheduling a reminder into her work calendar that pops up daily at 5:15 PM with the message, "Leave!" (D) Taking work home each night on a laptop computer.

During a clinical rotation on the medical-surgical floor of a hospital, you notice several patients have developed urinary tract infections (UTIs) associated with their Foley catheters (tubes inserted into the bladder to drain urine). Your staff physician agrees that this is a problem and offers to help with an improvement project. Together, you work through several PDSA cycles to reduce the rate of UTIs on your floor. When designing the run chart, it is important to include: (A) Units of time on the Y axis (B) The rate of UTIs on the X axis (C) Units of time on the X axis (D) A and B

Which of the following is a rule for determining non-random patterns? (A) A run of six points or more (B) An astronomical point (C) A trend of three points or fewer (D) A and B

(D) A and B

Why is psychological safety a crucial component of a culture of safety? (A) Without it, people won't be interested in improvement work. (B) It allows people to remove unsafe members of the team quickly. (C) Without it, patients will not follow their doctors' advice. (D) It allows people to learn from mistakes and near-misses, reducing the chances of further errors.

(D) It allows people to learn from mistakes and near-misses, reducing the chances of further errors. In psychologically safe environments, people understand that making mistakes is rarely a sign of incompetence, and that they won't be judged for discussing mistakes. Because of that, people are able to call out errors - whether their own or others' - and improve the processes that made the errors possible.

Aim: Reduce the average waiting time in the emergency department (ED) to 30 minutes by next August. Average number of minutes in the ED per patient (A) Outcome measure (B) Process measure (C) Balancing measure

(A) Outcome measure

Within the following data set, what is the median? [2.5, 7.2, 2.5, 2.9, 4.7, 3.6, 4.7] (A) 2.5 (B) 3.6 (C) 4.0 (D) 4.7

(B) 3.6

By June of 2015, we will reduce the incidence of pressure ulcers in the critical care unit by 50 percent. (A) Strong (B) Weak

(A) Strong

The charge nurse in the emergency room asks Brenda to assemble a team to improve the delivery of pain medication. As she considers who to place on the team, Brenda should: (A) Review the aim statement to make sure the team includes representatives of all processes affected by the team's aim. (B) Create a team of volunteers. (C) Create a team of managers and administrators. (D) Make sure only nurses are on the team, as they are the most likely to help her achieve her aim.

(A) Review the aim statement to make sure the team includes representatives of all processes affected by the team's aim.

Regarding the Seton network goal for spread, which of the following is true? (A) They surpassed it. (B) They met it exactly. (C) They failed to meet it. (D) The goal was unclear, so it was unclear whether they met it.

(A) They surpassed it. The Seton Family of Hospitals set a spread goal to introduce 15 medical-surgical units to TCAB by June 2007. At project completion, they had exceeded the initial goal: 17 units were using the TCAB process within 18 months.

According to sociologist Everett Rogers' attributes of spreadable ideas, ideas that spread naturally are: (A) Trialable (B) Complex (C) Intriguing (D) Groundbreaking

(A) Trialable One characteristic of ideas that spread naturally is trialability — that is, there is the opportunity for people to test the idea in a safe setting. The other four characteristics, according to Everett Rogers, are relative advantage, compatibility, simplicity, and observability.

When increasing the number of patients or events from one PDSA cycle to the next, it is usually helpful to multiply by what number? (A) 2 (B) 5 (C) 10 (D) 20

(B) 5 The 5X Rule recommends an increase by a factor of five whenever you finish one successful test and move on to the next.

When drawing a histogram, which is a good number of categories to include on your X axis? (A) 1-5 (B) 6-12 (C) 13-24 (D) >24

(B) 6-12

Which of the following describes data stratification? (A) Plotting observations to show the relationship between two sets of data (B) Classifying and separating data according to specific variables (C) Plotting data over time (D) Illustrating the relative frequency of occurrence

(B) Classifying and separating data according to specific variables

Starting with small tests of change: (A) Allows you to start testing on live patients right away (B) Improves the likelihood of buy-in from opinion leaders (C) Means you don't need to do any planning before each test (D) Should be done only with the consent of opinion leaders

(B) Improves the likelihood of buy-in from opinion leaders

Aim: Reduce the incidence of ventilator-associated pneumonia (VAP) by reducing the number of ventilator days in the intensive care unit (ICU) by 20 percent within five months. Readmission of ventilated patients to the ICU who then require mechanical ventilation (A) Outcome measure (B) Process measure (C) Balancing measure

Which of the following is a summary of Kurt Lewin's model of change? (A) Introduction, testing, implementation (B) Research, communication, measurement (C) Unfreezing, changing, re-freezing (D) Collaboration, integration, standardization

During Brenda's first group meeting, the members ask to review the aim statement to make sure they agree it addresses the current problem. With Brenda's approval, they all decide to rewrite it. However, when they meet to consider what would be a better aim statement, the group loses direction. In order to help them, Brenda might want to: (A) Reconsider who should be on the improvement team. (B) Move the meeting to a later date, so that she can come better prepared. (C) Explain to the group that the aim is set, as both she and the charge nurse have already agreed on the wording. (D) Remind the team of the Institute of Medicine's dimensions of health care quality.

(D) Remind the team of the Institute of Medicine's dimensions of health care quality.

What's the main benefit of using change concepts to come up with improvement ideas? (A) Using change concepts makes PDSA cycles unnecessary. (B) Using change concepts makes it much more likely that the implementation will go smoothly. (C) Using change concepts will lead you to focus on quantifiable technological improvements. (D) Using change concepts can help you develop specific improvement ideas that might not have occurred to you initially.

(D) Using change concepts can help you develop specific improvement ideas that might not have occurred to you initially.

The term "normalized deviance" refers to: (A) Acceptance of events that are initially allowed because no catastrophic harm appears to result. (D) The standard deviation of a variable in a "bell curve" distribution. (E) The increase in disturbing song lyrics in modern music. (F) Innovation based on observing positive outliers in a production process.

(A) Acceptance of events that are initially allowed because no catastrophic harm appears to result. Paradoxically, the fact that weak signals do not result in harm is what makes them most dangerous. When a weak signal is ignored (perhaps many times) and no harm results, workers integrate it into their conception of what is normal. Statements like "we always do it that way" may indicate underlying complacency. This acceptance of unsafe, ineffective, or inefficient routines is called normalized deviance.

An innovation in the United States that is spreading is the concept of a "medical home." Medical homes are meant to be a comprehensive, integrated approach to primary care. The people developing medical homes believe that providing care this way will improve access, patient satisfaction, and patient-centeredness — and improve clinical outcomes. Implementing a medical home involves redesigning the clinic system on a large scale and changing many behaviors of the staff and providers. As of yet, there is limited and conflicting data about whether medical homes lead to improved clinical outcomes. ABC Medical Center's leadership team has implemented the medical home model in one pilot site. Now the team wants to spread the innovation to other sites, and it is using IHI's Framework for Spread. Which of the following should the spread team do? (A) Ask staff to give daily feedback, to assess progress along the way. (B) Avoid asking staff for feedback at any point, to convey that the new system is mandatory. (C) Ask staff for feedback on the idea prior to implementation only, to encourage and then enforce staff buy-in. (D) Ask staff to try the new system for a year before giving feedback, so they have time to adjust to the new system before critiquing it.

(A) Ask staff to give daily feedback, to assess progress along the way. The best answer is to solicit daily feedback. One key factor in IHI's Framework for Spread is knowledge management, which includes gathering information about the spread process as it unfolds. Waiting a year to gather feedback is too long.

You volunteer at a student-run clinic associated with your academic health center. As a member of the student board, you are constantly looking for ways to improve the clinic. One common complaint is that it takes too long to check patients in once they arrive, and you decide to tackle this problem. Which of the following might be an outcome measure for this effort? (A) Average number of minutes between patient arrival at the clinic and completion of check-in (B) Number of patients seen by the clinic (C) Average number of students helping to check a patient in (D) None of the above

(A) Average number of minutes between patient arrival at the clinic and completion of check-in

Gathering and reviewing data during an improvement project—that is, measuring—helps you answer which of the three questions of the Model for Improvement? (A) How will we know that a change is an improvement? (B) What are we trying to accomplish? (C) What changes can we make that will result in improvement?

(A) How will we know that a change is an improvement?

Personality and work style profile assessments can help to: (A) Identify the personalities present and work to everyone's strengths. (B) Identify why some people will never respond well to change. (C) Determine who has the right expertise to be on an improvement team. (D) A and C

(A) Identify the personalities present and work to everyone's strengths. Personality and work style profile assessments help us understand how different people prefer to perceive the world and make decisions. This can be valuable — particularly if team leaders appreciate these differences and design the work to accommodate diverse preferences.

You volunteer at a student-run clinic associated with your academic health center. As a member of the student board, you are constantly looking for ways to improve the clinic. One common complaint is that it takes too long to check patients in once they arrive, and you decide to tackle this problem. Which of the following is the best way to collect baseline data for this improvement project? (A) Look at a few patients every day for a week. (B) Look at 10 percent of patients for a year. (C) Look at 100 percent of patients for a month. (D) There is no reason to collect baseline data.

(A) Look at a few patients every day for a week.

Aim: Reduce the incidence of ventilator-associated pneumonia (VAP) by reducing the number of ventilator days in the intensive care unit (ICU) by 20 percent within five months. Percentage of patients with ventilator-associated pneumonia (A) Outcome measure (B) Process measure (C) Balancing measure

(A) Outcome measure

Which of the following charts would be best to justify focusing on a few large problems and ignoring many smaller ones? (A) Pareto chart (B) Scatter plot (C) Histogram (D) Run chart

(A) Pareto chart

Which of the following changes falls under the heading of "eliminating waste"? (A) Physicians type all consult responses directly into a computer rather than writing them in a patient's chart, thus saving paper. (B) Dispensers full of hand sanitizer are placed throughout a floor, thus improving compliance with hand hygiene protocols. (C) A clinic starts tracking the number of foot exams that diabetic patients receive each year, thus ensuring they receive evidence-based care (D) A hospital invites patients to participate in the redesign of one of its centers, thus making them feel like valued members of a care team

(A) Physicians type all consult responses directly into a computer rather than writing them in a patient's chart, thus saving paper.

Imagine that your health care organization is trying to reduce worker fatigue. Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town. What would be a good way for the team to respond to the resistance to the change? (A) Share data that shows the process change is associated with a decrease in adverse events. (B) Abandon the idea. (C) Tell a story about a patient whom medical science was able to save. (D) A, B

(A) Share data that shows the process change is associated with a decrease in adverse events. The best answer is to share data that shows the process change is associated with a decrease in adverse events. Many people find compelling data to be persuasive. Some people are more motivated by stories. However, the story needs to be directly related to the change in order to be persuasive.

Why should you consider collecting a family of measures when undertaking an improvement? (A) It makes the project more publishable. (B) A single measure may not be enough to determine the impact of a change on the system. (C) All improvement projects are so complex that they require multiple measures. (D) All of the above

(B) A single measure may not be enough to determine the impact of a change on the system.

In designing a performance improvement team, it is helpful to: (A) Choose people who are unlikely to disagree with one another (B) Have a mix of different types of people on the team (C) Have everyone on the team exhibit similar personality preferences (D) All of the above

(B) Have a mix of different types of people on the team A healthy mix of personality types helps ensure a team captures many perspectives on an issue.

Dr. Gonsalvez, the medical director of the medicine ward, wants to lower the 30-day readmission rate of the patients on her unit (i.e., the percentage of patients readmitted to the hospital within 30 days of discharge). She meets with the nurse manager and other stakeholders, and, together, they develop a process to improve the way the ward discharges patients and transfers care back to each patient's primary care provider. The team tests the change on the ward and runs multiple PDSA cycles to improve the process. The data look promising. What improvement project phase have Dr. Gonsalvez and her team just completed? (A) Spread (B) Pilot (C) Implementation (D) Planning

(B) Pilot The team has just completed the improvement stage that consists of early, rapid-cycle tests of change: the pilot phase.

Aim: Reduce the average waiting time in the emergency department (ED) to 30 minutes by next August. Patient cycle times (e.g., time to registration, time from arrival to triage, time from triage to bed placement) and the percentage of time nurses arrive for their shifts early (A) Outcome measures (B) Process measures (C) Balancing measures

(B) Process measures

Your improvement team is trying to improve outcomes for patients with diabetes who are younger than age 18. You need a baseline measure for the percent of patients in the population you're studying who have hemoglobin A1c (blood sugar) levels greater than 8. You request this information from your information systems department, located in the central office. Then you wait. And wait. And wait. Frustrated, you decide to take matters into your own hands Which of the following is the best plan for collecting data? (A) Review all the charts for a four-month period, of which there are 210. (B) Select a sample of 10 charts from each of the four months to review. (C) Review a sample of the first 40 charts in chronological order. (D) Skip baseline data collection because it's not important for this project.

(B) Select a sample of 10 charts from each of the four months to review.

A hospital is trying to implement a new patient assessment form. They want to first test the usability and efficacy of the form. When determining sample size for the first test, it is most important to: (A) Look at similar research to see what sample size other organizations use. (B) Weigh the potential consequences of a test that does not lead to improvement against the belief in success. (C) Use a random sampling technique, so results can be extrapolated. (D) Ask all staff members what sample size they think should be used.

(B) Weigh the potential consequences of a test that does not lead to improvement against the belief in success. With improvement work, you should weigh the potential consequences of a test that does not lead to improvement against the belief in success. How small your first PDSA cycle should be rests on your degree of belief and the stakes involved.

You're working on an improvement project at a community mental health center. Your project aim: "Within two months, 100 percent of our patients will wait less than 30 minutes to be seen by a physician." You decide to gather data on patient wait times over a week-long period in order to establish a baseline. What might be an important consideration as you plan your data collection strategy? (A) Whether you'll provide food for the patients who wait more than 30 minutes. (B) What exactly you mean by "wait less than 30 minutes to be seen" — does this include the time the patient spends checking in, for instance? (C) How to establish consensus among the clinic's caregivers about the value of the project before gathering data. (D) How to inform the supervisors of individual physicians quickly when those physicians' patients wait more than 30 minutes.

(B) What exactly you mean by "wait less than 30 minutes to be seen" — does this include the time the patient spends checking in, for instance?

The Model for Improvement begins with three questions designed to clarify the following concepts: (A) Plan, do, act (B) Mission, goal, strategy (C) Aims, measures, changes (D) Will, ideas, and execution

You're an administrator at a hospital in a fast-growing suburb. Your hospital has hired three new orthopedic surgeons, including a new chief. These new hires are likely to triple the number of knee replacements done in your hospital. Currently, this procedure is done infrequently, and each time it feels a bit chaotic. As you consider the number of individuals with specialized skills required to execute a safe, effective knee replacement (nurses, surgeons, and anesthesiologists, as well as pre-operative, operating room, and post-operative staff), you realize that this process has the properties of a complex system. A few weeks after the new chief of orthopedic surgery comes on board, she has a moment of inspiration and sketches out a new, radically different way for patients to "flow" through the pre-operative, intra-operative, and post-operative phases. She sends you an email saying that she wants you to meet with her Monday morning to begin implementing it. Which of the following should you keep in mind as your hospital redesigns the way it handles knee replacements? (A) Planning by a multidisciplinary team should allow for the development of an excellent, high-functioning system on the first try. (B) Planning a new complex system for health care delivery has little in common with planning an industrial production process. (C) How system components are integrated with one another is as important as how well they function independently. (D) To ensure buy-in, the leader of the design process should be as high up in the organizational hierarchy as possible.

(C) How system components are integrated with one another is as important as how well they function independently. Any complex design process should begin with excellent component processes and materials. But such components will not, by themselves, result in an excellent overall result. How components (and component processes) are integrated is a key to overall outcomes. This is as true for a medical care process as it is for an industrial design process. Even with a committed multidisciplinary team, it is very rarely, if ever, possible to get everything right on the first try. Finding flaws after initial implementation (and opportunities for further improvement) should be expected and embraced. While commitment to innovation, excellence, and continual improvement should be supported from the very top of an organization, the actual leadership of the design process should be at the level that will serve best to engage those who have the deepest knowledge of the workflows and component activities, and can engage the multidisciplinary design team.

Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient's earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. In this scenario: (A) Rose is right; Dave is just being difficult. (B) Dave is probably too busy and that is why he is throwing up roadblocks. (C) Dave's behavior is normal; everyone has some challenges when adapting to new things.

You notice that it's very easy to confuse medications at the community health center where you're working. They are lined up on the shelf and the labels are very similar. You decide that it's worth a try to highlight parts of drug names on certain labels to reduce confusion. Which change concept are you using? (A) Manage Time (B) Optimize Inventory (C) Design Systems to Prevent Errors (D) Improve Work Flow

According to Herbert Kaufman, which of the following are reasons health care workers commonly resist change? (A) The expected autonomy of health care workers (B) A real or perceived limit on resources (C) An accumulation of policies, procedures, regulations (D) All of the above

(D) All of the above The best answer is all of the above. In his book The Limits of Organizational Change, Herbert Kaufman identified all of these as potential barriers to implementing change in health care.

When adapting to new change, most people fall into which of the following two categories? (A) Innovators and early majority (B) Early adopters and innovators (C) Early majority and early adopters (D) Early majority and late majority

(D) Early majority and late majority

As a nurse manager of a medicine unit in an academic hospital, you're aware that your unit has a high rate of patient readmissions. In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days. After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent. What would you identify as the outcome measure for the project? (A) Average length of stay (B) The cost of labor associated with the calls (C) Rate of job satisfaction of those on the unit making the calls (D) Percentage of patients that are readmitted to the hospital

(D) Percentage of patients that are readmitted to the hospital

Imagine that your health care organization is trying to reduce worker fatigue. Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town. Which of the following represents a culture change? (A) The planned nap (B) The designated room for the nap (C) The staff education about the nap (D) The belief that a planned nap can support patient safety

(D) The belief that a planned nap can support patient safety The culture change is the fundamental belief that a planned nap can support patient safety and that napping is okay during a shift.

What are the four phases of an improvement project? (A) Plan-Do-Study-Act (B) Innovation-Pilot-Study-Act (C) Plan-Implement-Pilot-Spread (D) Innovation-Pilot-Implementation-Spread

(D) Innovation-Pilot-Implementation-Spread The four phases of an improvement project are "Innovation-Pilot-Implementation-Spread." Plan-Do-Study-Act (PDSA) cycles are tests of change that improvers conduct during different phases of their improvement projects.

What is the order of the four steps teams typically follow to get to a place where they are running smoothly? (A) Forming, storming, norming, performing (B) Norming, performing, forming, storming (C) Storming, forming, norming, performing (D) Performing, storming, forming, norming

(A) Forming, storming, norming, performing Mary Dolansky explained a four-step process by which teams to get to a place where they are running smoothly: forming, storming, norming, and — finally — performing.

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. After you speak up, which of the following responses by the pharmacist would best indicate that this pharmacy has a culture of safety? (A) "Thanks! I'll tell your supervisor that you helped me today." (B) "If you know what's good for you, you won't tell anyone about this." (C) "Thanks! But in the future, please correct me in private, when others aren't around." (D) "Thanks! I appreciate that. But don't ever say something like that to the other pharmacist here. He's got quite a temper."

(A) "Thanks! I'll tell your supervisor that you helped me today." In a culture of safety, all individuals value safety. Those who help prevent errors should be rewarded, not punished or told not to repeat their behavior. If this were an especially strong culture of safety, the pharmacist would also suggest sharing his error with the rest of the staff and changing the system to make medication mix-ups less likely. Answer B is threatening and Answer C is likely to be confusing to the learner. Answer D shows that although this pharmacist may value safety, the rest of the group does not.

Peter, a patient with atrial fibrillation (heart arrhythmia), is placed on warfarin, a blood thinner, by his cardiologist. Peter goes to clinic weekly to have his INR, a measure of how thin his blood is, checked. One week he does not get a call after his bloodwork, and the week after he is admitted to the hospital with a bleeding ulcer. His INR that night is 6, indicating his blood is dangerously thin. A team conducts an RCA. One root cause the team identifies is that the cardiology clinic does not have a specific method to make sure they reach all patients with INRs and communicate their results by the end of the week. The RCA team prepares and shares a summary of their work. What should it contain? (A) A clear description of what happened, root causes, and recommendations for prevention. Team members and methods should be included. (B) A clear description of what happened, root causes, and recommendations for prevention. Estimated costs for implementation should be included. (C) A general description of what happened, root causes, and recommendations for prevention. Team members and methods should be included. (D) A general description of what happened, root causes, and recommendations for prevention. Estimated costs for implementation should be included.

(A) A clear description of what happened, root causes, and recommendations for prevention. Team members and methods should be included. Communicating the findings of an RCA is a crucial step towards improving patient safety. A presentation (or report) should include a clear description of what happened, the root causes of the event, and recommendations for how to prevent the error from occurring again - mirroring the goals of the RCA itself. It should also describe who was on the RCA team and what methods they used to gather and interpret information.

Having a clear aim statement is important in quality improvement work because: (A) Aim statements provide a clear and specific goal for the organization to reach. (B) All grant agencies require clear aim statements when they are considering funding requests. (C) Aim statements remove all obstacles from quality improvement projects. (D) The leaders of all organizations expect to see these types of goals.

(A) Aim statements provide a clear and specific goal for the organization to reach.

The radiology department you work in has had an unusual number of errors in the past year. Specifically, several patients have undergone procedures entirely different from the ones ordered. Unfortunately, the department does not have a culture of safety, and open discussion of mistakes is almost unheard of. Despite the current culture, you decide to try and form an improvement team to address these errors. In order to help foster a culture of safety, which of the following is an action you should consider taking? (A) Develop a plan to ensure that everyone in the department is clear about the problem. (B) Keep a list of who is participating in the effort and who is not. (C) Make plans to randomize your change efforts so your results can be published. (D) File an anonymous complaint with the hospital against the department leadership.

(A) Develop a plan to ensure that everyone in the department is clear about the problem. In this case, communicating clearly about the problem and asking others in the department to contribute ideas could be considered to be a type of briefing - that is, a form of structured communication that makes it easier for people to speak up when working in teams. Briefings are an important tool for establishing a culture of safety. Answer B would be counter to the concept of psychological safety. Answer C would be important if your main goal were to ascertain the effectiveness of a particular type of intervention as part of a research project; however, since your main goal is improvement in a complex system, randomization is not critical for success. Finally, while Answer D might get results, an anonymous report wouldn't necessarily help foster a culture of safety on its own.

The general surgery unit is working on reducing the number of catheter-associated urinary tract infections (UTIs) it causes. After some hard work, the unit has finally seen rates, which are reported monthly, come down for the first time by 20%. Unfortunately, the next month, the UTI rates on the general surgery unit are worse. After some investigation, it appears that many physicians are leaving catheters in longer at the request of their patients or family members. As the Medical Director of the unit, what would be your best next step? (A) Develop a short pamphlet for patients explaining the importance of early catheter removal in preventing infections. (B) Tell the physicians not to worry about what the patients or their families want. (C) Develop a nurse-driven plan so that catheters are automatically removed without physician approval. (D) Wait a month or two and see if the data improves.

(A) Develop a short pamphlet for patients explaining the importance of early catheter removal in preventing infections. Patients and their families are important resources in the quality improvement efforts. It's important to provide information to engage them in their care. Trying to "work around" the physicians by creating a nursing-only driven protocol, though an inventive solution, may be counter-productive and even lead to tensions between the physicians and nurses.

One reason it's critical for caregivers to improve their teams' effectiveness is: (A) Effective teams reduce the risk of errors by providing a "safety net" for individual caregivers. (B) Effective teams limit the number of caregivers patients have to speak with, reducing confusion among patients and families. (C) Teams rely less on technology and more on human capabilities, thus leading to better care. (D) All of the above

(A) Effective teams reduce the risk of errors by providing a "safety net" for individual caregivers. Effective teams — teams whose members communicate often and reciprocally — act as a kind of "safety net" that can help prevent errors resulting from one member's fatigue or distraction, for instance. Effective teams may still use technology often, and it's likely that patients and families will encounter many members of the team.

You are Georgia, a nighttime Nursing Aide. It is your job to turn patients on a set schedule, to prevent pressure ulcers. Jim, a quadriplegic patient, has been refusing to be turned. What should you do? (A) Explain to Jim why this is important and ask him about his concerns. (B) Pass this information along to the day nurse at the end of your shift. (C) Make a note of his refusal in your documentation. (D) Turn him anyway; he cannot stop you.

(A) Explain to Jim why this is important and ask him about his concerns. Patients should be engaged in the safety process. This requires explaining to them what you are trying to do to improve their care. Passive acceptance of his refusal is not in Jim's best interest, and turning him without an explanation is disrespectful and could be dangerous.

Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient's earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. Using Everett Rogers' theory of adoption of innovation, which category of adopter best describes Rose? (A) Innovator (B) Early adopter (C) Early majority (D) Late majority (E) Laggard (F) Not enough information to tell

(A) Innovator

Which of the following is a problem with static data? (A) It doesn't adequately portray variation. (B) It is often inaccurate. (C) It can't display mean, median, or mode. (D) All of the above

(A) It doesn't adequately portray variation.

Mary was an excellent nurse with 30 years' experience in obstetrics. On this particular day, she was sitting across the desk from the nursing supervisor, tears rolling down her cheeks. "I don't know how it could have happened," she said. A pregnant woman who had come to the hospital healthy, with a healthy fetus and an uneventful pregnancy, had suddenly stopped breathing and appeared unresponsive and paralyzed. When the patient's status began to deteriorate rapidly, Mary called the code team and started mouth-to-mouth resuscitation. The code team was able to stabilize the mother and fetus, but they were perplexed by the situation. It was at this time that Mary recognized her error: She had opened the wrong IV and administered the wrong medication to the patient — magnesium instead of saline was running at maximum rate. Which of the following is true? Select all that apply (A) Mary could be considered a second victim. (B) The error happened because Mary didn't care about her job. (C) Mary may need emotional support even though neither the mother nor her child suffered permanent harm.

(A) Mary could be considered a second victim. (C) Mary may need emotional support even though neither the mother nor her child suffered permanent harm. As you learned at the start of this lesson, people in Mary's situation are sometimes called the "second victims" of an adverse event. Caregivers may be severely traumatized when patients in their care are harmed — especially conscientious, committed caregivers like Mary, the kind of employee an organization would really want to have on staff — even when the harm is not permanent. An organization should take special steps to support these "second victims" after an adverse event.

When considering your role within a health care team, it is important to keep in mind that: (A) No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective. (B) You may be part of a team, but will likely be able to work autonomously without much input or help from others. (C) Teamwork skills will come naturally to you, because we all learn them in other settings. (D) You will need to be a good team member until you become an expert in your field, at which point you probably won't need teamwork skills.

(A) No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective. If you're entering any field in which you'll be caring for patients, it's a certainty that you will be a member of a team; in fact, you may be a member of multiple teams. As such, you'll have the responsibility to communicate effectively, value the contributions of other members, and keep building your team's ability to provide excellent care. Teamwork skills don't come naturally to everyone (Answer C), but anyone can learn and practice them.

Which of the following is NOT one of the key components of the IHI Framework for Spread? (A) Piloting innovation (B) Better ideas (C) Setup (D) Social system

(A) Piloting innovation The pilot phase of an improvement project occurs before the spread effort, as a prerequisite. The improvement team will initiate a spread plan only if the pilot is successful.

You're a medical assistant at a community health clinic. Sometimes, patients with unresolved problems need to come in for follow-up appointments. However, you notice that it's a real challenge to schedule these follow-ups within a week of the initial appointments. Which of the following techniques might be most useful as you search for a good idea for change? (A) Review the process for scheduling these appointments with colleagues to identify opportunities for improvement. (B) Quit and start working in a new clinic that functions more effectively. (C) Research possible upgrades to the appointment scheduling software. (D) Tell a member of the office staff that it would be great if follow-ups were scheduled more quickly.

(A) Review the process for scheduling these appointments with colleagues to identify opportunities for improvement.

As the Health Unit Coordinator (HUC), it is your job to enter orders from providers into the computer system. Direct provider order entry is planned for your hospital next year when the electronic health record is implemented. You check charts every couple of hours for new orders, unless the providers "flag" the chart by turning a dial on its side to red — in which case, you check the chart right away. On a particularly busy day, you see a chart tucked in a corner and realize that you have not looked at it in at least six hours. Worse, you check the order dial and see that it's partly red. On the order sheet are orders for "STAT" pain medications and antibiotics for a new patient. You quickly input the orders, your heart pounding. Three hours later, the patient is transferred to the intensive care unit with worsening sepsis (infection). When your supervisor informs you about what happened, you go numb thinking about those six hours and the cost to the patient. What should ideally happen? (A) She should speak calmly with you about what happened and how you're feeling about it. (B) She should remind you that these errors happen to everyone and they're no big deal. (C) She should encourage you to stay busy at work, to help you move past the incident. (D) She should suspend you immediately, so that you have a couple of weeks to process what happened and learn from your mistake.

(A) She should speak calmly with you about what happened and how you're feeling about it. Ideally, supervisors are trained to spot issues when they arise and to talk calmly with practitioners about what happened. Depending on the circumstances, the caregiver may need to take a break, go home, or take some time off — but there is no reason in this case to think you should be involuntarily suspended.

If you are responsible for the initial communication with the patient about the error, which of the following should you be sure to do? (A) Speak clearly and directly (B) Disguise any feelings of concern or remorse (C) Explain the exact cause of the error (D) All of the above

(A) Speak clearly and directly It is important to acknowledge that the event occurred by speaking clearly and directly. You probably don't know exactly what caused the error at the time of the initial communication, but that's OK. Rather than completely disguising your feelings, you should express empathy and compassion.

Some types of actions tend to be weaker and other actions tend to be stronger, regardless of context. Let's take a look at a few possible actions below. Is the action relatively strong, intermediate, or weak? Replace all IV pumps in the hospital with a single model. (A) Strong (B) Intermediate (C) Weak

(A) Strong Standardization of equipment is a powerful way to reduce the likelihood of errors.

Some types of actions tend to be weaker and other actions tend to be stronger, regardless of context. Let's take a look at a few possible actions below. Is the action relatively strong, intermediate, or weak? Remove unnecessary and dangerous steps from a process. (A) Strong (B) Intermediate (C) Weak

(A) Strong This simplifies the process and thus makes it less prone to error.

Prathibha, a 29-year-old woman, is recovering from same-day knee surgery. While in the post-anesthesia care unit (PACU), she unexpectedly goes into acute respiratory failure and requires intubation. Because she is a young, healthy woman with no medical problems and this was a very unexpected outcome, the charge nurse convenes a team to conduct a root cause analysis. As the RCA for this case begins, the team struggles with identification of the root causes of the outcome. They consider the patient's characteristics as well as the work environment. According to Charles Vincent, what other areas should they consider? (A) Team factors, institutional context, and organizational factors (B) Budget, human nature, and organizational factors (C) Team factors, human nature, and PDSA cycles (D) Psychology, PDSA cycles, and management factors

(A) Team factors, institutional context, and organizational factors In his papers on this topic, Charles Vincent lists seven categories of factors that influence medical practice and error. These include patient characteristics, task factors, individual staff member characteristics, team factors, work environment, organizational and management factors, and institutional context.

Sandy Liu, a cardiac care unit nurse, notices that a few of her patients are suffering from inadequate pain control. Currently, a patient who needs pain medication must call the front desk, which then calls the nurse, who then goes to the patient's room to find out what he or she needs. Sandy finds out that a hospital in the next county has a simpler process: Patients can send a text message directly to the nurse to request pain medication. Sandy goes to her manager and suggests that they form a team to work on improving pain control and test this change in the cardiac care unit. How should Sandy and her improvement team try out the new process for improving pain control? (A) Test the new process with one patient and closely review the results. (B) Bring together a group of stakeholders to develop an implementation plan. (C) Test the new process throughout the hospital to build a pool of data. (D) None of the above: There is no need to test this process because another hospital has already proved it to be effective.

(A) Test the new process with one patient and closely review the results. The best answer is "test the new process with one patient on and closely review the results." Sandy and her team have an innovation and are ready to conduct a pilot. (Every organization is different, so just because the idea worked at another hospital does not mean it will work here.) Piloting involves starting small, such as with one patient, and carefully refining the change to make sure it works.

When you are graphing a proportion or a percent, what should you look at to help you understand the bigger picture? (A) The denominator of the measured value (B) The numerator of the measured value (D) The median of the denominator (E) The median of the numerator

(A) The denominator of the measured value By tracking the denominator of the measured value, you can confirm that your improvement effort is really showing signs of success, and there are not other factors at work.

On a particularly busy night in the emergency department, a patient comes in with chest pain. The triage nurse, who's been on the job only two days, takes the patient's information, fills out the form, and puts the patient's chart on the rack so he'll be seen in the order in which he arrived. She mentions to a passing nurse, "There's a patient here who has pain — he's waiting to be seen." Thirty minutes later, still waiting to be seen, the patient collapses in the waiting room. What likely contributed to this outcome? (A) The lack of a shared plan for patients with chest pain resulted in a failure to act quickly. (B) The high patient volume caused a long delay in caring for a patient with a critical condition. (C) A new nurse was placed in triage, which was not safe. (D) No clear standard of care exists for chest pain patients, so the nurse couldn't have known what to do.

(A) The lack of a shared plan for patients with chest pain resulted in a failure to act quickly. A clear plan for patients with chest pain, including the use of structured communication about the nature of his pain, would have allowed the triage nurse to act much more quickly in this case. Clear standards of care exist for such patients in terms of triage, but in this case, the triage nurse did not know of any explicit plan based on those standards.

LaTonya, a young woman with diabetes, dies after being admitted for a kidney infection. What might an RCA NOT be able to uncover? (A) The medical resident caring for her did not know the appropriate antibiotics for this type of infection. (B) There are 23 steps between ordering an antibiotic and administering it on the unit. (C) The new electronic medical system does not have a mechanism to flag "stat" antibiotics for pharmacy. (D) Fatigue among residents is contributing to unsafe care.

(A) The medical resident caring for her did not know the appropriate antibiotics for this type of infection. One concern with RCAs is that by focusing upon systems, those reviewing errors may overlook issues that point to individual issues, such as deficits in knowledge. Answers B, C, and D describe clear system issues that would likely be uncovered through the RCA process.

Ben, a 36-year-old patient with Type I diabetes mellitus and kidney failure, comes to the hospital to have a special arteriovenous fistula placed in his arm to allow him to begin dialysis in a few weeks. The fistula was supposed to be placed on the left arm, but the surgical team accidentally operates on the opposite arm, not realizing until the procedure is finished. When Ben wakes up from anesthesia, he sees a bandage on his right arm and is confused. What should happen right away? (A) The mistake should be communicated to Ben and the hospital's administrators. (B) The mistake should be posted on a blog along with an explanation of the events. (C) The entire surgical team should be reprimanded, as it was not only the responsibility of the surgeon. (D) All of the above

(A) The mistake should be communicated to Ben and the hospital's administrators. The hospital should communicate right away with Ben and his family about the mistake, and administrators also need to know about it, so they can start investigating what happened and changing processes to avoid such an event in the future. It is likely that punishing those involved should be avoided. Although posting information publically may be a good idea, the patient and his family must be attended to first.

Imagine that your health care organization is trying to reduce worker fatigue. Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town. In the example, which of the following is a process change? (A) The planned nap (B) The data that show whether staff members are taking a planned nap (C) The belief that a planned nap can support patient safety (D) None of the above

(A) The planned nap The process change is the planned nap. It is the method by which the organization hopes to decrease worker fatigue.

A ten-year-old is admitted to the emergency room with new symptoms of abdominal pain and vomiting for four hours. He has elevated glucose (450 mg/dl), and his urine has ketones, indicative of severe diabetes. He is given fluids and admitted to the intensive care unit, where a second glucose remains very elevated at 260. In the early hours of the morning, when the nurse finds him unresponsive, she calls an emergency code. The cardiac arrest team arrives, begins resuscitation, and obtains a glucose of 560, which is sky-high. The boy is finally treated with IV insulin and recovers with appropriate treatment. "I want to apologize for not treating your son effectively or quickly in a way that would have allowed us to avoid the awful experience that he had during his first night here. We should have started him on insulin as soon as we made the diagnosis, either in the emergency room or in the intensive care unit, and instead we didn't do that. When I've talked to our staff, I think that what we now understand is that while we have many adults who come into the emergency room with new diabetes, we don't have a lot of kids, and so the adults we treat pretty quickly and pretty aggressively. With children, and with your son, the staff just acted much more timidly and were a little bit less sure than we certainly would like them to be. I apologize and we apologize. Going forward, what we've discussed is we've set up a group to look at the treatment of children. What we have planned is that when kids come in, we will immediately call the senior staff who know how to treat children properly. I know that this isn't going to help your family, but I hope that this is going to make a difference for kids in the future. What's important from my standpoint now is making sure that we take the best care of your son moving forward, and that you know we'll be available to you to answer any of your questions and to make sure that things unfold smoothly from this point onward." If you were the patient's parents, what would you hear "between the lines" of this conversation? (A) The provider is showing empathy right away. (B) The provider is acknowledging his fallibility. (C) The provider is minimizing your feelings. (D) The provider has identified actions to prevent recurrence of the mistake.

(A) The provider is showing empathy right away. (B) The provider is acknowledging his fallibility. (D) The provider has identified actions to prevent recurrence of the mistake. The best answers are A, B, and D. In this clear apology, the provider shows empathy, takes responsibility, talks about his remorse, clarifies what happened, details the plans to remedy the defects in care, and assures the patient and family that the health care organization will work in their best interest. This is a full apology.

On a particularly busy night in the emergency department, a patient comes in with chest pain. The triage nurse, who's been on the job only two days, takes the patient's information, fills out the form, and puts the patient's chart on the rack so he'll be seen in the order in which he arrived. She mentions to a passing nurse, "There's a patient here who has pain — he's waiting to be seen." Thirty minutes later, still waiting to be seen, the patient collapses in the waiting room. During a debriefing, it becomes clear that a nursing assistant was concerned about a patient's breathing just after a drug was administered, but he did not feel comfortable telling the physician. What conclusion can you draw about the unit where this adverse event occurred? (A) The unit's culture doesn't effectively promote psychological safety. (B) There are too many patients in the ICU. (C) The unit's lack of an electronic health record endangers patients. (D) None of the above

(A) The unit's culture doesn't effectively promote psychological safety. Effective health care organizations actively promote psychological safety — a feeling that it's okay to speak up and discuss past or potential errors. Within these organizations or units, all staff members know that their safety concerns will be treated with respect and that unprofessional, bullying behavior won't be tolerated.

Why should a RCA be conducted by a team rather than by an individual? (A) Understanding what led to an error requires diverse perspectives. (B) A team helps the RCA move more quickly. (C) Individuals usually are not equipped to complete the intense RCA process on their own. (D) Teams are better able to stand up to the conflict that usually comes about when the results of the RCA are made public.

(A) Understanding what led to an error requires diverse perspectives. Health care is complex. Discovering why an error took place requires multiple perspectives from people in different professions. Working in a team may upon occasion slow the process down, but it will improve the quality of the outcome.

Which is an important approach when conducting an RCA? (A) Use categories to organize events that led to errors. (B) Focus on a single process in order to consider it in depth. (C) Consider the costs involved in addressing the problems found during the process. (D) Avoid focusing on patterns.

(A) Use categories to organize events that led to errors. In an RCA, we group the events that led to the error (or near miss) into categories, so that the most important and crucial work processes can be addressed. Discerning patterns of this kind is important, as is considering a broad range of processes from which problems might have arisen. Although costs may need to be considered later on, this is not part of an RCA.

What famous Italian economist is credited with the theory behind the 80/20 rule? (A) Vilfredo Pareto (B) Benedetto Cotrugli (C) Joseph M. Juran (D) Michelangelo Histogram

(A) Vilfredo Pareto

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. You decide to speak with the pharmacist while he is filling the order. What would be the most appropriate thing to say? (A) "Did you check the bottle from which you're dispensing that medication?" (B) "I am concerned there is a safety issue here." (C) "What are you doing? Can I help?" (D) "Stop filling that prescription right now or I will be forced to call the manager."

(B) "I am concerned there is a safety issue here." When speaking up, it is important to use clear, direct language. Words like "safety" or "concerned" can get people's attention. Hinting at a problem, such as in Answer A, is not sufficient. Likewise, using threats, as in Answer D, is not professional behavior. Answer C is the vaguest option, and it's least likely to result in a solution to the problem.

You are Georgia, a nighttime Nursing Aide. It is your job to turn patients on a set schedule, to prevent pressure ulcers. You decide to say something to the Nursing Aide who seems to be ignoring the plastic clocks. As you mention that she has not turned any patients this shift, she interrupts and says, "Look, I have a lot of sick patients tonight. Turning will just have to wait until things settle down!" What would be a reasonable response? (A) "Sorry." (B) "I did not mean to imply that you were not doing your job. I just wanted to help remind you on a busy day." (C) "I only wanted to help. But now that you have been disrespectful, I will speak to our supervisor tomorrow." (D) Just walk away. It is not worth starting a fight, and you need to preserve your relationship with her.

(B) "I did not mean to imply that you were not doing your job. I just wanted to help remind you on a busy day." Your fellow Nursing Aide seems to be defensive about having her behavior pointed out. Making your reason for speaking clear, so that she knows you were only trying to help, can go a long way to bringing her on board.

You are Georgia, a nighttime Nursing Aide. It is your job to turn patients on a set schedule, to prevent pressure ulcers. Two weeks later, you are again on a night shift as a Nursing Aide. Things have been busy, with a late admission and a patient who needed to go to the Emergency Department. About 6 hours into your 12-hour shift, the other Aide mentions that you are behind in turning patients. What should be your response? (A) "I was just getting to that. It's been super busy." (B) "Thank you for reminding me. I'm a little behind tonight." (C) "There is no way I will be able to get to this unless I skip some of my other duties." (D) "I have never forgotten before."

(B) "Thank you for reminding me. I'm a little behind tonight." Nobody is perfect. When you are caught making a mistake, admit this and thank the person for reminding you. This way, they will be more likely to speak up again to others. Also, this is a golden opportunity to model what their behavior should be in the future if someone points out that they are doing something unsafe.

Janice is a nurse on the orthopedics unit. This night, she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later, she realizes, to her dismay, that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, "Why won't someone help me?" Janice quickly administers the morphine. Why is it important for Janice to apologize to Mrs. Bernardo for the delay in her pain medication? (A) It is not necessary to apologize in this case. (B) An apology is needed to maintain provider-patient trust. (C) All institutions require an apology. (D) An apology will prevent the patient relations department from becoming involved.

(B) An apology is needed to maintain provider-patient trust. Janice should apologize because it will help to maintain trust between the patient and her providers — even if there is no permanent injury in this case, the patient certainly experienced more pain than necessary. Although some institutions do not require an apology, providers might want to engage their institutions to reconsider this policy. Apologies should not necessarily prevent the patient relations department from becoming involved after adverse events.

According to the World Health Organization (WHO), how could at least half a million deaths due to surgical error be prevented every year? (A) By developing better surgical technology (B) By implementing systemic changes in operating rooms (D) By inflicting stronger punishments for those who commit medical errors (E) By weeding out reckless surgeons

(B) By implementing systemic changes in operating rooms At least half a million deaths per year could be prevented with effective implementation of systemic improvements in operating rooms. Specifically, multiple studies have found implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical morbidity and mortality due to surgical errors.

With which of their following statements would you agree? (A) Health care outcomes for most illnesses are no better than they were 40 years ago. (B) Care has become more complex and specialized during the last 40 years. (C) Care has become simpler and more straightforward during the last 40 years. (D) There is no more focus on the quality and safety of health care than there was 40 years ago.

(B) Care has become more complex and specialized during the last 40 years. There is no question that health care has become, overall, more complex in the past four decades. Increased diagnostic technology, treatment options, and specialization have all added to the complexity (and costs) that patients see, but have also improved health outcomes for most conditions. In the case of breast cancer, and for many other acute and chronic illnesses, the number of individuals (and disciplines) involved in a single patient's care has increased dramatically. This has made communication and coordination among various physician and non-physician providers more critical than ever to providing safe and effective care. It should be noted that the number of specialists involved with a patient varies dramatically depending on where a patient lives, a patient's proximity to large medical centers, and the number of specialists who practice nearby. It is not always the case that more care is better care. Research shows that areas with relatively more medical specialists do not produce higher-quality care, higher patient satisfaction, or lower mortality.

Yesterday, you showed up at work to discover that your colleague was out sick, so your patient load was higher than usual. While making your rounds, you quickly read the chart of a patient recovering from a total hip replacement. The patient had been suffering from nausea secondary to the morphine prescribed to treat his pain, so you switched him to a different pain medication, hydromorphone. Today, you've arrived at work again, and the patient's nurse meets you to explain that the patient became disoriented and combative last night. You realize with horror that, in your hurry, you miscalculated the conversion from one narcotic to another and accidentally ordered a seven-fold overdose of medication to an elderly patient. If you were the caregiver in this situation, what would be the very next thing you ought to do? (A) Apologize to the patient. (B) Check on the patient and, if necessary, stabilize him. (C) Respond to the patient's concerns about what might happen next. (D) Share what you know about the adverse event with the team caring for the patient and try to determine the cause.

(B) Check on the patient and, if necessary, stabilize him. The first action upon discovering an adverse event always is to take care of the patient's physical needs. If the patient is hurt, stabilize him or her. Take action both to ensure that the patient doesn't experience further harm and to mitigate the effect of the harm that has already occurred. Preparing for the initial communication should take place after caring for the patient's immediate clinical needs.

Which of the following is an example of transparency? (A) Firing the physician with the lowest patient satisfaction ratings each year (B) Discussing a time when you made an error similar to one that just occurred, and explaining what you learned (C) Making sure that all data regarding errors are seen only by senior leadership (D) Making sure that all data regarding errors are stripped of identifying information

(B) Discussing a time when you made an error similar to one that just occurred, and explaining what you learned Transparency means being open with information, including information that reveals that none of us is perfect. Discussing an error in which you were involved will help others to do the same. Answer A is a "blame and shame" response that is likely to discourage transparency among staff, and Answer C does not provide information to the front-line staff who need to see it. While some data may need to be stripped of identifying information to maintain patient confidentiality, having all data presented this way (Answer D) may inadvertently send the messages that people should hide information and that errors are shameful.

Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient's earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. Using Rogers' theory of adoption of innovation, which category of adopter best describes Joan? (A) Innovator (B) Early adopter (C) Early majority (D) Late majority (E) Laggard (F) Not enough information to tell

(B) Early adopter

(B) Fairness Holding all employees to the same standards of professional behavior, regardless of position, is an example of fairness.

Peter, a patient with atrial fibrillation (heart arrhythmia), is placed on warfarin, a blood thinner, by his cardiologist. Peter goes to clinic weekly to have his INR, a measure of how thin his blood is, checked. One week he does not get a call after his bloodwork, and the week after he is admitted to the hospital with a bleeding ulcer. His INR that night is 6, indicating his blood is dangerously thin. A team conducts an RCA. One root cause the team identifies is that the cardiology clinic does not have a specific method to make sure they reach all patients with INRs and communicate their results by the end of the week. Which of the following is the best recommended action statement? (A) The nurse in charge of calling patients with their results should be replaced. (B) Have the phlebotomy lab automatically generate a list of patients all patients who had INRs drawn that day and email them to the nurse, with space to note if the nurse has reached the patient with their results, so that 99% of patients receive calls within two days of their results. (C) Patients need to have their INRs checked more frequently. (D) Patients awaiting lab results should be given access to MyChart, a part of the electronic health record that allows them to access their lab results themselves.

(B) Have the phlebotomy lab automatically generate a list of patients all patients who had INRs drawn that day and email them to the nurse, with space to note if the nurse has reached the patient with their results, so that 99% of patients receive calls within two days of their results. Good recommendations contain ideas for improving the system, as well as ideas for measuring that improvement. Answer B has both of these characteristics. A is punitive and not systems-based, and C does not directly address the problem of the lack of follow-up by the clinic. D, although a good idea, does not contain a measurable outcome.

The "setup" component of IHI's Framework for Spread is best defined as: (A) Tracking and monitoring spread progress (B) Identifying the target population and the initial strategy to reach all sites in the target population with the new idea (C) Understanding the relationships within the system (D) Assessing innovations and identifying those that are of value

(B) Identifying the target population and the initial strategy to reach all sites in the target population with the new idea The best answer is "identifying the target population and the initial strategy to reach all sites in the target population with the new idea." Understanding the relationships within the system falls under the "social" component of IHI's Framework for Spread, and tracking and monitoring progress falls under "measurement and feedback." The identification and piloting of worthwhile innovations should occur before leaders attempt to spread those innovations throughout a system.

An orthopedic clinic in a busy metropolitan area would like to improve its patient scheduling process. More specifically, the clinic wants to improve its efficiency and the satisfaction of its patients. Applying the Model for Improvement to the clinic's improvement goal, which of the following is the most reasonable aim statement? (A) Implement two PDSA cycles within six months of beginning the project. (B) Increase the number of patients reporting they are "very satisfied" with the clinic's scheduling by 50 percent within six months. (C) Modify the scheduling process to allow both front desk staff AND nurses to directly schedule appointments. (D) Create an efficient process for scheduling return appointments at the time of checkout.

(B) Increase the number of patients reporting they are "very satisfied" with the clinic's scheduling by 50 percent within six months.

Some types of actions tend to be weaker and other actions tend to be stronger, regardless of context. Let's take a look at a few possible actions below. Is the action relatively strong, intermediate, or weak? Add more nurses to a unit. (A) Strong (B) Intermediate (C) Weak

(B) Intermediate A decreased workload may decrease errors because staff members are not rushing around as much. However, adding more people doesn't automatically lead to safer care.

Seton's Chief Nursing Officer was a key supporter of the TCAB spread effort. Which component of IHI's Framework for Spread does this fact best represent? (A) Communication (B) Leadership (C) Setup (D) Measurement

(B) Leadership The best answer is "leadership." Executive leaders in an organization play an important role in spread initiatives by supporting and facilitating the efforts. The ultimate success and sustainability of TCAB depended on leadership commitment at all levels: from the senior executives who set strategic priorities and ensured that good changes spread, to midlevel clinical leaders who empowered staff and orchestrated change, to local leaders and staff who redesigned care processes to achieve unprecedented patient outcomes.

A 62-year-old man with a two-week history of fatigue, shortness of breath, and easy bruising is seen at a primary care clinic on a Saturday morning. Lab work drawn the day before shows the patient to be anemic and having abnormalities with white blood cells. The patient is pleasant, but fatigued, and becomes short of breath walking to the exam room. A blood smear shows numerous abnormal white blood cells. The clinic physician tells the patient that something is wrong with his blood and recommends admission to the hospital. The patient agrees, and the physician calls his colleague in the hospital emergency room. The clinic physician makes the following statements. Which part of the statement is the background? (A) I have Mr. Chan, a 62-year-old man whom I believe has acute myelogenous leukemia. (B) Mr. Chan has a two-week history of fatigue, shortness of breath, and easy bruising. He was seen yesterday with lab revealing a hematocrit of 24 and numerous immature white cells in the peripheral smear. (C) Mr. Chan needs admission and a hematologic workup. (D) I'd like to send Mr. Chan to you. He has agreed to admission and can be there in about 30 minutes.

(B) Mr. Chan has a two-week history of fatigue, shortness of breath, and easy bruising. He was seen yesterday with lab revealing a hematocrit of 24 and numerous immature white cells in the peripheral smear.

As the Health Unit Coordinator (HUC), it is your job to enter orders from providers into the computer system. Direct provider order entry is planned for your hospital next year when the electronic health record is implemented. You check charts every couple of hours for new orders, unless the providers "flag" the chart by turning a dial on its side to red — in which case, you check the chart right away. On a particularly busy day, you see a chart tucked in a corner and realize that you have not looked at it in at least six hours. Worse, you check the order dial and see that it's partly red. On the order sheet are orders for "STAT" pain medications and antibiotics for a new patient. You quickly input the orders, your heart pounding. Three hours later, the patient is transferred to the intensive care unit with worsening sepsis (infection). Why is it important for the organization to offer you help and support at this time? (A) The organization is legally obligated to do so. (B) Offering support helps prevent depression or decreased job satisfaction. (C) Offering support decreases the institution's legal risk following the error. (D) Offering support decreases the risk of future errors.

(B) Offering support helps prevent depression or decreased job satisfaction. There is evidence that the providers involved even in minor errors and near misses can suffer from feelings of shame, depression, and guilt. Sometimes they can be unable to continue their work. Even if the organization has no legal obligation to provide help for providers involved in adverse events, doing so may prevent these negative consequences.

You're a new resident (house officer). At 2:00 AM, you receive a phone call about a patient you are covering who has diabetes. The patient has an elevated blood sugar of 375. You order 12 units of NovoLog (rapid-acting) insulin and ask the nurse to check the sugar again in one hour and call you back. One hour later, the sugar is 280, so you order another 10 units. By 4:00 AM, the patient's sugar is dangerously low at 45. You realize that NovoLog insulin takes two to three hours to reach peak effect. By rechecking the patient's glucose after only one hour and giving more insulin so quickly, you set the patient up for an episode of hypoglycemia. Which of the following is true regarding communication about adverse events with patients? (A) Information openly communicated to patients about adverse events in their care cannot be used in court. (B) Open communication with patients can assuage caregivers' feelings of guilt. (C) Due to its complexity, communication with patients following adverse events is best done by lawyers. (D) All of the above

(B) Open communication with patients can assuage caregivers' feelings of guilt. Communicating about adverse events to patients and families can assuage the feelings of guilt that commonly arise among health care providers. Training in communication is helpful, but communicating after an adverse event is not unduly complex, and it should be done by those directly involved in the incident. The information communicated may be used in court, although laws may vary on this subject from state to state and country to country.

Aim: Reduce the incidence of ventilator-associated pneumonia (VAP) by reducing the number of ventilator days in the intensive care unit (ICU) by 20 percent within five months. Average number of days on mechanical ventilation (A) Outcome measure (B) Process measure (C) Balancing measure

(B) Process measure

The team conducting Quinn's RCA begins work. What should their first step be? (A) Review the medical literature. (B) Review Quinn's medical records and interview providers. (C) Develop causal statements using Charles Vincent's framework. (D) Review anonymous opinions from providers as to the reasons for this incident, and then construct a list of the most common.

(B) Review Quinn's medical records and interview providers. The first step of an RCA is to identify what happened. This can be done by reviewing charts and records, and by interviewing the patient, family, providers, and any other relevant personnel. Reviewing literature and developing causal statements are part of an RCA, but they occur later in the process. Obtaining opinions might be helpful, but this is not a standard part of the RCA.

When an adverse event befalls a patient, who are the "second victims" according to Dr. Albert Wu? (A) The patient's family (B) The caregivers involved in the error (C) The risk managers who become involved in the error (D) Other patients who might experience the same error in the future

(B) The caregivers involved in the error The term "second victim," coined by Dr. Albert Wu, highlights the devastation that caregivers can suffer when they are involved in a medical error, as well as their need for support from colleagues and their institution. After an adverse event, the caregivers involved may feel upset, guilty, self-critical, depressed, and scared. In addition, their job satisfaction, ability to sleep, relationships with colleagues, and self-worth can be negatively affected.

(B) The provider is minimizing your feelings. (C) The provider is minimizing the impact of the disease on the patient. (D) The provider is self-aggrandizing. The best answers are B, C, and D. This provider ignores the patient's experience and minimizes the impact of the new disease on the patient and the family. Rather than taking responsibility for the poor care delivered, the provider is self-aggrandizing, boasting about the organization's excellent care. In this particular case, withholding the information that the patient should have been more aggressively treated is almost lying.

Root cause analyses can be useful in health care because: (A) They help to assign blame. (B) They help to identify system failures that can be corrected. (C) They are often quick and simple to perform.

(B) They help to identify system failures that can be corrected. Root cause analyses are systematic approaches to understanding an error (or a near miss), with the hopes of identifying systems failures that can be addressed. They are not used to assign blame, nor are they necessarily quick. They are retrospective, occurring only after an error has happened.

What is the purpose of IHI's Framework for Spread? (A) To spread health education to underserved communities (B) To spread improvements across health systems (C) To eliminate the spread of disease (D) To ensure accurate spread of information

(B) To spread improvements across health systems IHI's Framework for Spread is a useful way to think about the most important components to consider when developing and executing a strategy to spread improvements across health systems.

Which of the following is an example of an effective measurement technique for improvement? (A) Always strive for perfection. (B) Use quantitative and qualitative data. (C) Always set aside designated time for data collection. (D) All of the above

(B) Use quantitative and qualitative data.

Which of the following statements is true? (A) All changes lead to improvement; therefore, all improvement requires change. (B) While not all changes lead to improvement, all improvement requires change. (C) The changes that are known to lead to improvement should be implemented before testing.

(B) While not all changes lead to improvement, all improvement requires change.

Brenda, an emergency room nurse, notes that there seems to be a significant delay between the ordering and the administration of pain medications in her department. She decides to conduct a small improvement project to reduce this delay and obtains the support of the charge nurse (head nurse). Which of the following is the most effective aim statement for this project? (A) Within one month, 95 percent of physicians will tell nurses when a pain medication is ordered on emergency room patients. (B) Within three months, the emergency department will administer all pain medications within 45 minutes of order time. (C) Within two months, improve the timeliness of pain medication delivery by allowing nurses to stock the most commonly used medications in the emergency unit (D) Within three months, the emergency department will improve the timeliness of pain medication delivery to 100 percent of patients.

(B) Within three months, the emergency department will administer all pain medications within 45 minutes of order time.

At the large multi-specialty clinic in which you work, there have been two near misses and one medical error because various clinicians did not follow up on patient results. Different caregivers were involved each time. After the second near miss, the physician involved was asked to leave the clinic. A nurse who realized that his colleagues weren't consistently following up on patient results reported the problem to the clinic leadership right away. Which response would be most consistent with a culture of safety? (A) Transferring the nurse to another clinic (B) Writing a letter of commendation for his file (C) Thanking the nurse and asking him to keep quiet about it (D) Placing the item on the agenda for the leadership meeting next year

(B) Writing a letter of commendation for his file Rewarding someone for bringing a problem to your attention is an example of effective leadership and also helps support psychological safety throughout the organization. Asking someone to keep quiet sends the message that the clinic values neither safety nor transparency. Finally, putting something on an agenda for a meeting to be held next year does not send a message that safety is an immediate concern.

In a run chart, the variable being measured is typically placed on what axis? (A) X axis (B) Y axis (C) Either axis (D) Neither axis; the run chart does not compare variables.

(B) Y axis

You find yourself speaking to the patient before you know the details of the prescribing and administration errors. That is, you are pretty sure that you prescribed an inappropriately large dose, but you don't know how much medication the patient received or who administered it. What do you tell the patient? (A) You experienced harm due to a medical intervention. We think your nurse gave you the wrong dose of medication. I wrote the prescription for it incorrectly. We're looking into it now. (B) Your problem seems to be the result of receiving the wrong dose of medication. Our number-one concern right now is to make sure that you are safe, and we will take care of you with the best skill and experience available. As soon as we've done that, we're going to figure out what happened and tell you. I am very sorry that this happened. (C) I cannot tell you what happened. You have to wait until we complete our investigation. (D) We believe you had an allergic reaction to a medication. Although it was no one's fault, we are sorry it happened.

(B) Your problem seems to be the result of receiving the wrong dose of medication. Our number-one concern right now is to make sure that you are safe, and we will take care of you with the best skill and experience available. As soon as we've done that, we're going to figure out what happened and tell you. I am very sorry that this happened. Your job right now is to acknowledge the event, express regret that it happened, and explain whatever you do know for certain. Don't speculate at this point. You might say something like, "I am so sorry this happened to you. I can't imagine what this must feel like for you, although I will try." Answer A is not the best answer because the cause of the error is not yet clear. The words used in this response not only assign blame perhaps prematurely but will undermine any trust the patient has in the care team. In your initial discussions with patients, you should not place blame. Remember, you don't yet know the facts, and your speculation may make the patient more alarmed. Answer C is also not the best answer because, although there may be no information as to the cause of the error, not acknowledging that the patient has experienced a medical error may lead to psychological harm and create suspicion. Answer D is not the best answer because it is not true. Remember, not only do patients want the truth, they deserve it.

The general surgery unit is working on reducing the number of catheter-associated urinary tract infections (UTIs) it causes. After some hard work, the unit has finally seen rates, which are reported monthly, come down for the first time by 20%. Rhonda, one of the senior nurses in the unit, already feels overworked. Although she does not have an official leadership title, she is well respected by others. During a staff meeting, she raises her hand and says, "I think that we are wasting our time working on these UTI rates. It takes time away from the care of our patients." As the Medical Director of the unit, which of the following would be your best response? (A) "I understand your concerns. Let's meet together and talk right after we finish." (B) "Some of the other nurses can focus on this if you would prefer. We will figure out another project for you." (C) "Although I understand that we all feel busy, improvement work is part of everyone's job." (D) "An attitude like this is why you do not have a leadership position on the unit."

(C) "Although I understand that we all feel busy, improvement work is part of everyone's job." Knowing when and how to speak up to people who are not as interested in improving patient outcomes is a crucial aspect of success in this area. It is often important to have at least part of this conversation in public, so that everyone knows that you value this work, and that you also understand the other person's challenges. If you let the senior nurse quit the project or make her feel bad about not having an official leadership position, nothing will be gained.

Which statement best describes a team? (A) A group of people who work together (B) A group of people who try to accomplish the same goal (C) A group of people who work together in a coordinated way, which maximizes each team member's strengths, to achieve a common goal

(C) A group of people who work together in a coordinated way, which maximizes each team member's strengths, to achieve a common goal A team is more than just a group of people who work side by side. A team is a group of people who work together in a coordinated way, which maximizes each team member's strengths, to achieve a common goal. Such a group can anticipate mistakes, overcome obstacles, and navigate difficult situations.

When an error occurs, which of the following is generally the proper order of prioritization? (A) Communicate with the patient, report to all appropriate parties, check the medical record, care for the patient. (B) Report to all appropriate parties, check the medical record, care for the patient, communicate with the patient. (C) Care for the patient, communicate with the patient, report to all appropriate parties, check the medical record. (D) Check the medical record, care for the patient, communicate with the patient, report to all appropriate parties.

(C) Care for the patient, communicate with the patient, report to all appropriate parties, check the medical record. The first priority is to address the current health care needs of the patient. After caring for the patient's immediate clinical needs, start preparing for the initial communication session with the patient and/or the patient's representative. Various people, departments, entities, or agencies may need to be notified that there has been an adverse event, so once the immediate patient needs are addressed, you'll want to make sure the proper parties are informed. The last concern is making sure the medical record contains a complete, accurate record of the clinical information pertaining to the unanticipated adverse outcome.

Quinn is a three-year-old boy with a congenital heart malformation. While recovering in the pediatric intensive care unit after surgical correction, he is accidentally given a tenfold dose of heparin. Although he suffers no permanent injuries, the leadership of the hospital rightly decides to conduct a root cause analysis. As they assemble the team, it is crucial that they do the following: (A) Include Quinn's parents. (B) Put together a team of mostly nurses and physicians. (C) Create a team of members who fulfill several roles. (D) Include the health care providers involved in Quinn's care.

(C) Create a team of members who fulfill several roles. Root cause analysis teams need to be diverse in order to be able to see as many viewpoints as possible. While patients and families, as well as the providers involved, may be included in the teams, there is by no means consensus about whether to include these individuals. Interprofessional teams are strongly encouraged, but there is no hard-and-fast prescription for which professions should be included or what the balance of the professions should be. Ideally, the team will include people with a strong understanding of the areas and processes involved in the case.

(C) Fairness Although multiple providers were involved in these near misses and mistakes, only one provider was asked to leave. This is not fair, because others clearly could have made (and did make) the same mistake, suggesting the problem was based in a system error rather than reckless behavior by an individual. Answer B, "orderliness," is certainly desirable - but it is not a core characteristic of a culture of safety.

The heart of the RCA process is: (A) Doing a complete and thorough reconstruction of what happened before the event. (B) Defining what should have happened for the patient. (C) Identifying what caused the event. (D) Creating a fishbone diagram.

(C) Identifying what caused the event. The heart and soul of an RCA is the identification of the root causes of an error, so that the organization can change the system to prevent similar future errors. Although the other answers are all steps in the RCA, they are not the central feature of the process.

A hospital is trying to implement a new patient assessment form. They want to first test the usability and efficacy of the form. Let's say the hospital has an English-speaking nurse (Nurse Moss) assess one English-speaking patient with the new form. It is a successful test and the improvement team wants to increase the scale of the next test. What would they do? (A) Have a Spanish-speaking nurse give the assessment to one of her Spanish-speaking patients. (B) Have a different English-speaking nurse give the assessment to one of her English-speaking patients. (C) Increase the number of patients Nurse Moss assesses by a factor of 5. (D) Increase the number of patients Nurse Moss assesses by a factor of 10.

(C) Increase the number of patients Nurse Moss assesses by a factor of 5. The best answer is to increase the number of patients Nurse Moss assesses by a factor of 5. Scale is the number of interactions within the test — in this case, the number of patients receiving the assessment, and the 5X Rules recommends an increase by a factor of five in each subsequent test. Changing the conditions of the test — such as the language involved or the staff involved — would be a change in scope, rather than scale.

What else should the leadership do as they plan for the RCA? (A) Wait to conduct the RCA for a period of time, in order to let the emotions surrounding the incident subside. (B) Make sure that the team conducting the RCA is clear about what they can and cannot review from the records. (C) Make sure the team has time and resources to conduct the RCA, including access to advisors when necessary. (D) Make sure there is at least one member of the senior leadership on the team.

(C) Make sure the team has time and resources to conduct the RCA, including access to advisors when necessary. Conducting a high-quality RCA takes time and resources, and it is important that leadership makes sure these are both available to the team members. Senior leadership does not need to be on the team itself, and senior leaders may even be an impediment to drawing candid answers out of front-line staff. RCAs should be conducted quickly, before memories fade and attention is turned to newer problems.

You've got a summer job working at the headquarters of Jen & Berry's, an ice cream company. One day, the CEO herself (Jen, of course) walks by your desk. "We're testing a new flavor," she says, "Peanut Buttery Banjo Jamboree." She has high hopes customers will like the new flavor, and that it can replace "Chocolate Mocha Polka Party," the company's lowest-selling product. "But," she says, "we need some data to show that it's really an improvement." How would you figure out which flavor the company should sell? (A) Talk to an equal number of readers of "Chocolate Lovers Monthly" and "Peanut Butter Today." (B) Ask everyone in your region which flavor they prefer. (C) Poll a small sample of customers in the region, including proportional numbers of people who read "Chocolate Lovers Monthly" and "Peanut Butter Today." (D) Grab a couple of pints of ice cream and sample them both yourself!

(C) Poll a small sample of customers in the region, including proportional numbers of people who read "Chocolate Lovers Monthly" and "Peanut Butter Today."

(C) Practice leadership and the hospital leadership When communicating about the RCA, a final report or presentation to administrators and stakeholders is the minimum. Some of the individuals who should receive the report include organization leadership, department heads of those departments involved in the event, and members of the risk management and quality improvement departments. Teams may also share the report with the individuals involved in the incident, as well as the patient and his or her family. This underscores the fact that the RCA process is about improving patient care and not placing blame. If written in a blame-free tone, the RCA report helps those who were involved in an error move from possible guilt to action and prevention.

When giving an explanation for why an adverse event happened, it can sometimes be a good idea to: (A) Give whatever explanation you have at the time, even if some of the information is speculative. (B) Explain how the patient could have helped prevent the error. (C) Say something like, "There is just no excuse for what happened." (D) All of the above

(C) Say something like, "There is just no excuse for what happened." Sometimes the statement "There is no excuse for what happened," can be the most honest and dignified explanation at the time of your initial apology. Explanations may mitigate or aggravate the patient's feelings about an event, but they should be factual. The speaker must make it very clear that the patient did not do anything wrong.

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. Why should you tell the pharmacist about your concern? (A) So that the pharmacist will think well of you when completing your evaluation at the end of the rotation (B) So that you can make your knowledge and eye for details apparent (C) So that the patient does not experience an adverse event (D) So that the pharmacist gets some extra training

(C) So that the patient does not experience an adverse event Speaking up about safety concerns should be a patient-centered act. Your goal in voicing your concern is simply to ensure the patient receives safe and effective care — in this case, the correct medication. Voicing your concern should not be about displaying your knowledge, currying favor, or getting someone in trouble.

You are Georgia, a nighttime Nursing Aide. It is your job to turn patients on a set schedule, to prevent pressure ulcers. The nursing home decides to institute a plan to place plastic "clocks" on the outside of each patient room, denoting the next time they need to be turned. Tonight, you notice that one of the Nursing Aides appears to ignore these clocks throughout her shift. As far as you can tell, she has not turned any patients in hours. What should you do? (A) Mind your own business. (B) Try to turn her patients in addition to your own. (C) Talk to her about the importance of turning patients on a regular basis. (D) Tell her supervisor about her behavior.

(C) Talk to her about the importance of turning patients on a regular basis. It is everyone's job to work on safety and infection prevention in all care settings. However, we are also all human and can overlook these safety techniques when we're busy. So speaking to your co-worker, not with the intent to make her feel bad but rather to help her, is in order.

After assembling a team and working through the three questions of the Model for Improvement, the orthopedic clinic decides to implement an automated reminder phone call 24 hours prior to each clinical appointment. The clinic's improvement team hopes that this small change will improve scheduling. What is the team's next step? (A) Take a well-deserved break. (B) Develop their project-level measures. (C) Test their change plan using the PDSA cycle. (D) Report their results to clinic leadership and prepare a poster for a national meeting.

Imagine that your health care organization is trying to reduce worker fatigue. Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town. What's the likeliest reason the program failed? (A) The nap wasn't long enough. (B) The room for the nap was too noisy. (C) The culture of the organization did not support napping during a shift. (D) Workers weren't as tired as managers thought they were.

(C) The culture of the organization did not support napping during a shift. The program probably failed because the culture of the organization did not support napping on the job as a way to decrease worker fatigue and boost patient safety.

Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left ankle was operated upon rather than his right ankle. The surgical staff that operated on Mr. Reynolds is embarking on a root cause analysis (RCA) of the incident. If they complete a high-quality RCA, which of the following is an example of the kind of root cause they might identify? (A) The nurse did not listen to the patient. (B) The patient was male. (C) The hierarchy in the operating room had a negative effect upon communication. (D) In this particular case, there was nothing that anyone on the surgical team could have done to prevent an error such as this one.

(C) The hierarchy in the operating room had a negative effect upon communication. RCAs are meant to identify system failures that might place patients at risk for similar errors in the future. Poor communication due to hierarchy is one such reason. The nurse's failure to listen to the patient would be a symptom of the larger, "big-bucket" problem.

You meet with the nurse administrator responsible for improvement when issues in the process of care are identified by those on the wards. She listens carefully to your concern, but in the end says she can only try to help improve nursing issues, and not those that extend to pharmacy or transport. The primary reason your meeting is unlikely to lead to an adequate solution is: (A) No one is identified as responsible for improvement when abnormalities in the process of care are identified. (B) The responsible individual belittled the nurse reporting the problem. (C) The nurse administrator did not have the appropriate span of responsibility to engage the system components needed to solve the problem. (D) Since things have been going along without a serious adverse event for several months, it appears that the current work-around is effective.

(C) The nurse administrator did not have the appropriate span of responsibility to engage the system components needed to solve the problem. Steve Spear identifies a number of steps needed to fix problems in a production system. They include recognizing abnormalities; having an identified person to call, with the knowledge, attitude, and responsibility necessary to find a solution; and giving workers the time and resources to solve the problem. In the case of health care, this means treating the "system" as well as the "patient." The challenge here is that even though someone is designated, and that person may have the time to fix how work is done, the nurse administrator may not have the perspective and authority to work across boundaries of specialty, function, and discipline.

As a nurse manager of a medicine unit in an academic hospital, you're aware that your unit has a high rate of patient readmissions. In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days. After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent. Which of the following is an example of a process measure that you may collect as part of this improvement effort? (A) The rate of patients being readmitted within 30 days (B) The reasons for readmission to the hospital (C) The percentage of patients receiving a call within 48 hours of discharge (D) The cost of the labor associated with the calls

As a nurse practitioner in a small, rural urgent care clinic, you believe that your clinic team works well together. Which of the following facts would best support your belief? (A) Not a single complaint about unprofessional behavior has been filed by clinic members over the past year. (B) The providers work in rotating shifts and rarely need to transmit information from one shift to the next. (C) The team routinely takes a moment to discuss the plan and voice concerns before doing a procedure. (D) All of the above.

(C) The team routinely takes a moment to discuss the plan and voice concerns before doing a procedure. One of the main characteristics of strong health care teams is effective and frequent communication. The absence of unprofessional behavior (Answer A) does not necessarily mean the team is effective. And the failure to share information during shift changes is risky for patients (Answer B).

Which of the following is typically true of "weak signals"? (A) They usually result in harm to caregivers or patients. (B) They are uncommon. (C) They can combine with other human or environmental factors to result in catastrophe. (D) They should only be called out by specifically designated individuals within a health care organization.

(C) They can combine with other human or environmental factors to result in catastrophe. Weak signals that could be used to identify system deficiencies are common — and usually ignored. This is understandable since, by themselves, such signals do not result in direct harm. It is only when they combine with other factors that harm (and sometimes catastrophe) results. Examples in and out of health care abound, including NASA's Columbia Space Shuttle disaster, which, if the response to such signals had been more robust, could have been prevented. Since weak signals occur in daily work at all levels of an organization, each individual must see it as part of his or her job to identify and respond to such signals (or to "escalate" the problem up the hierarchy so that it can be fixed).

When planning a sequence of PDSA cycles for a change that involves patients, which of the following is a true statement? (A) Patient characteristics in each PDSA cycle should be as uniform as possible to allow valid comparisons. (B) The number of patients in each cycle should stay fixed, to allow valid comparisons. (C) We would expect the number of patients involved to grow rapidly from early cycles to later cycles. (D) None of the above

(C) We would expect the number of patients involved to grow rapidly from early cycles to later cycles. As improvement work progresses and the number of cycles increases, we would expect the scope and scale of the tests to increase, meaning both a rapidly growing number of patients involved in the tests as well as increasing diversity in the test population.

Some types of actions tend to be weaker and other actions tend to be stronger, regardless of context. Let's take a look at a few possible actions below. Is the action relatively strong, intermediate, or weak? Write a new hospital policy about patient transport. (A) Strong (B) Intermediate (C) Weak

Peter, a patient with atrial fibrillation (heart arrhythmia), is placed on warfarin, a blood thinner, by his cardiologist. Peter goes to clinic weekly to have his INR, a measure of how thin his blood is, checked. One week he does not get a call after his bloodwork, and the week after he is admitted to the hospital with a bleeding ulcer. His INR that night is 6, indicating his blood is dangerously thin. A team conducts an RCA. One root cause the team identifies is that the cardiology clinic does not have a specific method to make sure they reach all patients with INRs and communicate their results by the end of the week. The RCA team working on Peter's case develops several recommended actions. Which of the following is likely to have the strongest impact? (A) Assign more staff to the job of calling patients with their INR results. (B) Post signs reminding the staff to call patients with their INR results. (C) Work with the phlebotomy lab to automatically generate the names of all patients who had INRs drawn that day and send them in an email to the nurse responsible for patient follow-up. (D) Create a policy that specifies that patients with INRs must be called with their results within one week.

(C) Work with the phlebotomy lab to automatically generate the names of all patients who had INRs drawn that day and send them in an email to the nurse responsible for patient follow-up. Actions that are likely to have a strong impact rely on systemic fixes, such as creating a new process where none existed before. A process in which multiple departments work together to identify patients needing a phone call would likely have a strong impact. Posting signs may be a useful cognitive aid with intermediate impact; however, creating a policy or simply giving a job to more people without a clear process is likely to have a weak impact.

You're a new resident (house officer). At 2:00 AM, you receive a phone call about a patient you are covering who has diabetes. The patient has an elevated blood sugar of 375. You order 12 units of NovoLog (rapid-acting) insulin and ask the nurse to check the sugar again in one hour and call you back. One hour later, the sugar is 280, so you order another 10 units. By 4:00 AM, the patient's sugar is dangerously low at 45. You realize that NovoLog insulin takes two to three hours to reach peak effect. By rechecking the patient's glucose after only one hour and giving more insulin so quickly, you set the patient up for an episode of hypoglycemia. Why is it important to communicate with the patient about this event? (A) Open sharing of this type of information is necessary if patients are to trust their caregivers. (B) Open communication is essential according to numerous professional codes of conduct. (C) Open sharing of this type of information eliminates the risk of a lawsuit. (D) A and B

(D) A and B Open communication about all outcomes of care, including adverse events, is essential to establish and maintain patient-provider trust, and is viewed as a fundamental ethical requirement by many professional organizations, including the American Medical Association, the American College of Physicians, and others. Although open communication may decrease the risk of lawsuits, it does not eliminate all risk.

Sandy Liu, a cardiac care unit nurse, notices that a few of her patients are suffering from inadequate pain control. Currently, a patient who needs pain medication must call the front desk, which then calls the nurse, who then goes to the patient's room to find out what he or she needs. Sandy finds out that a hospital in the next county has a simpler process: Patients can send a text message directly to the nurse to request pain medication. Sandy goes to her manager and suggests that they form a team to work on improving pain control and test this change in the cardiac care unit. After a successful pilot, which of the following should Sandy's improvement team undertake as a next step? (A) Work on seeing that the change is widely adopted by the unit, such as by making it a formal policy and training new staff on it. (B) Continue to run PDSA cycles. (C) Spread the change to other hospitals in the network. (D) A and B

(D) A and B The best answer is "A and B." After a successful pilot, they should move on to the implementation phase. This phase includes actions to "hardwire" the change, such as making it standard policy and training new staff on it. In implementing the change, the team will continue to run PDSAs: making predictions, carrying out the test, collecting data, and refining the change based on results. (Note that compared to PDSAs in the pilot phase, these tests will require significantly more people, time, and resources.)

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. Which of the following is a factor that might make it difficult for you to say something to this pharmacist? (A) You're just a student, and health care is hierarchical by design. (B) The pharmacist got annoyed when someone corrected him earlier. (C) You do not have time to say anything today. (D) A and B

(D) A and B The best answer is A and B. While challenging authority figures requires courage in any field, the hierarchical nature of health care can make speaking up particularly difficult. This is especially true when senior practitioners get upset with junior staff who voice concerns about safety. Other reasons it may be hard to say something in this case include your respect for the pharmacist, concern that you are mistaken, and fear of being yelled at or mistreated. For learners, there's the additional worry that your evaluations and grades may be affected. However, it is always your place to speak up where safety is concerned, even if you're not certain you're right.

Which of the following are strategies to help members of a QI team establish common goals? (A) Create a team roster. (B) Share stories. (C) Write down a shared work plan. (D) All of the above

(D) All of the above The best answer is all of the above. Some strategies to help get everyone on the same page include: Create a team roster so everyone knows who is on the team and how to reach each other, share stories to establish why the QI project is personally meaningful to people, and write out a work plan.

You are shadowing a patient during her regular well visit with her primary care provider. You have defined the "care experience" as the time she checks in with the front desk until the time she leaves the office building. In addition to the patient's primary care provider, which of the following caregivers that the patient encounters should you record and include in your shadowing report? (A) The receptionist at the front desk (B) The medical assistant who collects the patient's height, weight, and vital signs (C) The lab technician the patient sees for blood work (D) All of the above

(D) All of the above A caregiver is any person whose work touches a patient's or family's experience, including: doctors, nurses, therapists, pharmacists, technicians, aides, dietitians, appointment schedulers, parking attendants, janitors, hospital leaders, supply chain employees, medical records clerks, financial representatives, and anyone else who comes into direct or indirect contact with the patient.

Which of the following communications strategies did the TCAB spread team use at Seton? (A) Regular meetings (B) One-to-one calls (C) A website (D) All of the above

(D) All of the above The best answer is "all of the above." Because communication is at the heart of spread, the spread initiative needs an organized communication campaign. It's helpful to use many types of communication.

What did Paul Levy do after handling the immediate fallout from the wrong-site surgery? (A) He proposed creating an instructional video about the experience that would be viewed at meetings and conferences. (B) He explained the event and the hospital's response to the public in a blog post. (C) He asked the general public for their thoughts and suggestions. (D) All of the above

(D) All of the above The best answer is all of the above. Paul Levy employed a multi-pronged approach to spread awareness of the error and the hospital's response to it, as well as collect feedback from the public. It's critical to communicate effectively after a preventable mistake, as patients often want to know what steps are being taken to prevent similar mistakes from occurring again. Further, being transparent about errors allows the entire organization — and even other organizations — to learn from them.

Which of the following statements is true about using data for improvement? (A) Both quantitative and qualitative data can be useful. (B) The data should tell a story. (C) A run chart is one of the most helpful tools for displaying data. (D) All of the above.

(D) All of the above.

Dr. Gonsalvez, the medical director of the medicine ward, wants to lower the 30-day readmission rate of the patients on her unit (i.e., the percentage of patients readmitted to the hospital within 30 days of discharge). She meets with the nurse manager and other stakeholders, and, together, they develop a process to improve the way the ward discharges patients and transfers care back to each patient's primary care provider. The team tests the change on the ward and runs multiple PDSA cycles to improve the process. The data look promising. Dr. Gonsalvez and her team continue to test the new idea. Assuming things continue to go well, what might they eventually do? (A) Share the innovation with other units and/or hospitals. (B) Utilize the IHI Framework for Spread. (C) Develop a communication and dissemination plan. (D) All of the above.

(D) All of the above. The best answer is "all of the above." After a successful pilot, the next steps are implementation and spread. IHI's Framework for Spread, which includes developing a communication and dissemination plan, is a helpful tool to use during the final phase of an improvement project.

When attempting to spread a change that you feel is valuable but is not spreading naturally, if possible, it's a good idea to: (A) Move on to something else that does spread naturally. (B) Use IHI's Framework for Spread. (C) Use the New Idea Scorecard. (D) B and C

(D) B and C Changes that do not spread naturally might benefit from IHI's Framework for Spread and from brainstorming with the New Idea Scorecard. You could switch to a different innovation that's easier to spread, but it would be wiser to use the tools available to you before abandoning a potentially valuable innovation.

Which of the following opinions did Dr. Robert Wachter express in his response to Paul Levy's blog about the wrong-site surgery of June 2008? (A) Coming out with the error in public was unwise. (B) The case was clear-cut and should not have been the subject of debate. (C) It was a mistake not to punish staff for cutting corners and neglecting rules. (D) Circumstances could exist where the providers were to blame for the error.

(D) Circumstances could exist where the providers were to blame for the error. Wachter felt that if the providers were routinely and knowingly negligent — in an environment where good systems did exist to prevent errors — they could be to blame and punishment might be warranted. However, it would still be a controversial topic and a tough balancing act of "no blame" versus accountability. Overall, Wachter praised Levy and commended in particular his public disclosure of the case.

You are a member of an intensive care unit team in a regional hospital. This morning, a patient had an unexpected severe allergic reaction (anaphylaxis) after being given a penicillin derivative. There was a significant delay in getting the physician involved and beginning treatment for this life-threatening condition. Fortunately, the patient is now stable and does not seem to be experiencing any lasting effects. At this point, what would an effective team leader do? (A) Report this adverse event in the anonymous reporting system so that it can be investigated (B) Ask administrators to launch an investigation immediately to find out who was responsible for this adverse event (C) Add this medication to the patient's allergy list (D) Conduct a debriefing

(D) Conduct a debriefing Debriefings occur after events to find out what happened and what could be done better next time. The most effective debriefings happen soon after the event, while memories are fresh. However, the first priority is the patient's health - so debriefings should only occur after the patient is stabilized.

Imagine you're a member of a newly formed improvement team that has taken up the challenge to reduce health care-associated infections at your hospital. You have an idea for a change to the room cleaning process that you want to test, but you're slightly nervous because improper cleaning and disinfection can carry a high risk for patients with compromised immune systems. You haven't run any PDSA cycles yet. Which of the following would be the best next step? (A) Have one housekeeper use the process with one room cleaning. (B) Have all housekeepers use the process for a week. (C) Have one housekeeper use the process on five room cleanings. (D) Confirm the "face validity" of the new cleaning process by demonstrating it with a couple of housekeeping staff members and a supervisor.

(D) Confirm the "face validity" of the new cleaning process by demonstrating it with a couple of housekeeping staff members and a supervisor. Based on your concern about patient safety, you'd likely first want to confirm the "face validity" of the new cleaning process by demonstrating it with a couple of housekeeping staff members and a supervisor. When testing changes that involve patients, it can be helpful to conduct an initial test using staff only. A simulation or practice session before going live is often a good way to uncover issues with high risk.

During a clinical rotation on the medical-surgical floor of a hospital, you notice several patients have developed urinary tract infections (UTIs) associated with their Foley catheters (tubes inserted into the bladder to drain urine). Your staff physician agrees that this is a problem and offers to help with an improvement project. Together, you work through several PDSA cycles to reduce the rate of UTIs on your floor. Which of the following methods would you recommend to display your improvement data? (A) Draw a bar chart. (B) Write a list of numbers. (C) Create a two-column table. (D) Draw a run chart.

(D) Draw a run chart.

You are a member of an intensive care unit team in a regional hospital. This morning, a patient had an unexpected severe allergic reaction (anaphylaxis) after being given a penicillin derivative. There was a significant delay in getting the physician involved and beginning treatment for this life-threatening condition. Fortunately, the patient is now stable and does not seem to be experiencing any lasting effects. The unit leaders are trying to figure out what changes they should make to prevent this treatment delay from happening again. Given what you know about the incident, what change would you recommend? (A) Implement mandatory debriefings after the team works together on a patient. (B) Fire the physician who failed to respond in a timely way. (C) Stop using nursing assistants in the ICU. (D) Implement the use of critical language in the ICU.

(D) Implement the use of critical language in the ICU. Critical language (such as "I need some clarity") is an agreed-upon phrase or set of words that indicates to all members of a patient care team that there is a problem. It helps individuals who need to call attention to a problem but don't know what to say, especially if the patient is awake and listening; and it also serves as a red flag to team members that they need to stop and pay attention. Critical language might have helped the nursing assistant speak up more quickly when he observed problems with the patient's breathing. Debriefings, which occur after the event, would be a valuable source of learning, but they would not be sufficient to prevent an event like this one in the future.

Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left ankle was operated upon rather than his right ankle. The team conducting the RCA of the wrong-site surgery realizes that one contributing factor was the pressure on surgical teams to start and end surgeries on time (so as not to disrupt later scheduled procedures). Which of Vincent's seven categories of factors influencing clinical practice does this best illustrate? (A) Patient characteristics (B) Team factors (C) Individual team member (D) Organizational and management factors

(D) Organizational and management factors When conducting an RCA, it is important to take a balanced look at errors. Charles Vincent identified seven categories of factors that influence clinical practice, including the four above. All seven should be considered when conducting an RCA. The pressure to complete surgeries on time most likely has its origin in organizational and management decisions.

What are some of the limitations of RCAs? (A) They are often conducted by those unfamiliar with the local context of the error and do not always produce actionable recommendations. (B) People participating in the RCA may not be familiar with how to conduct them, and the costs of implementing the actions may be too high. (C) They are often conducted by those unfamiliar with the local context of the error, and the costs of implementing the actions may be too high. (D) People participating in the RCA may not be familiar with how to conduct them, and they do not always produce actionable recommendations.

(D) People participating in the RCA may not be familiar with how to conduct them, and they do not always produce actionable recommendations. Individuals conducting RCAs in organizations are not always trained to do so, making the exercise difficult to complete. In addition, it can be quite difficult in some cases to find systematic changes that will prevent future errors.

You are Georgia, a nighttime Nursing Aide. It is your job to turn patients on a set schedule, to prevent pressure ulcers. Pressure ulcer rates drop in the facility, much to the delight of the medical and nursing directors reviewing the data. However, the staff are feeling frustrated with the extra work. Which of the following might help to ease their feelings? (A) A raise; only money works as a motivator. (B) Decrease the frequency with which they turn patients. (C) Nothing; this is just a normal response to change. It will eventually go away once the new procedure becomes ingrained. (D) Post the improved rates for all to see.

(D) Post the improved rates for all to see. Reporting data is critical in quality improvement; it can be a strong motivator of change, in addition to being a reward in and of itself as numbers improve. Keeping the people doing the frontline work informed about the results of their efforts helps them see the relevance - and the importance - of what they do.

The general surgery unit is working on reducing the number of catheter-associated urinary tract infections (UTIs) it causes. After some hard work, the unit has finally seen rates, which are reported monthly, come down for the first time by 20%. After your next round of efforts, the infection rates drop and then remain steady. They are lower than your initial rates, but not down to your target. You learn about a new catheter associated with lower infection rates, but also realize that these catheters are 20 percent more expensive than your current ones. When discussing a possible switch to these new, more expensive catheters with administration, which type of argument is most likely to be effective? (A) Inform administration that if they do not make the switch, you will tell the local papers. (B) Get others on your unit to sign a petition supporting the switch, and give the petition to the administration. (C) Create a PowerPoint presentation that highlights the features of the new catheter. (D) Present the scientific data on the improved outcomes, including costs of the new catheters and money saved with their use.

(D) Present the scientific data on the improved outcomes, including costs of the new catheters and money saved with their use. When reviewing decisions with administration, it is often most helpful to review the evidence and science. Additionally, having a clear understanding of the return on investment will often help leadership make the decision that the monetary investment will be worth the reward. This strategy would be much more likely to sway administration than presenting a petition, telling the local papers (which would only cast your facility in a negative light), or creating a presentation highlighting features of the new catheter instead of outcomes.

Janice is a nurse on the orthopedics unit. This night, she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later, she realizes, to her dismay, that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, "Why won't someone help me?" Janice quickly administers the morphine. Janice gives the following apology to Mrs. Bernardo: "Mrs. Bernardo, there was a delay in you receiving your pain medication that should not have happened. I am very sorry that you had unnecessary pain. The doctor gave me the order to give you a dose of morphine. However, I was caring for another patient who had fallen, and I got distracted and did not give you the medication as quickly as I should have. Again, I just want you to know how sorry I am that this happened." Which one of Aaron Lazare's four components of an apology is missing in Janice's apology? (A) Acknowledgment (B) Explanation (C) Expression of remorse or shame (D) Reparation

(D) Reparation Reparation, which may simply be an offer to check up more frequently on the patient overnight, is missing in this case. The apology clearly expresses remorse and acknowledges the event, and it provides an explanation without using it as an excuse.

An innovation in the United States that is spreading is the concept of a "medical home." Medical homes are meant to be a comprehensive, integrated approach to primary care. The people developing medical homes believe that providing care this way will improve access, patient satisfaction, and patient-centeredness — and improve clinical outcomes. Implementing a medical home involves redesigning the clinic system on a large scale and changing many behaviors of the staff and providers. As of yet, there is limited and conflicting data about whether medical homes lead to improved clinical outcomes. Which of the following is an accurate statement about the spread of this innovation? (A) This innovation has a high degree of simplicity, so it is likely to spread quickly. (B) Because the relative advantage of this new care model is highly apparent, it is likely to spread quickly. (D) The complexity of the change involved will likely slow the spread of this innovation. (E) There are obvious and low-cost ways to make this innovation more "trialable," which might help it spread more quickly.

(D) The complexity of the change involved will likely slow the spread of this innovation. Implementing an entirely new clinic system is quite complex, making this a difficult innovation to spread. Improved outcomes may take time to appear and may not be easily observable, which could also slow spread. Finally, because this innovation involves a large-scale system change in most cases, it is difficult to test this easily and in a safe setting. This analysis does not imply that the medical home is not an improvement — only that it may be more difficult to spread than less complicated innovations.

Prathibha, a 29-year-old woman, is recovering from same-day knee surgery. While in the post-anesthesia care unit (PACU), she unexpectedly goes into acute respiratory failure and requires intubation. Because she is a young, healthy woman with no medical problems and this was a very unexpected outcome, the charge nurse convenes a team to conduct a root cause analysis. Which of the following is an example of the type of causal statement that this team might expect to develop? (A) Prathibha hid her diagnosis of asthma, so the team was not aware of her respiratory risks. (B) The nurse responsible for Prathibha was unqualified to monitor complex medical patients. (C) Respiratory compromise can occur in patients with underlying conditions post-operatively. It is unlikely that this outcome could have been prevented. (D) The patient was unattended for 30 minutes because the nurse was busy caring for other patients, and this contributed to the outcome.

(D) The patient was unattended for 30 minutes because the nurse was busy caring for other patients, and this contributed to the outcome. RCAs are about identifying systems-based issues that contributed to an error, so that these issues can be corrected. Blame, such as in A and B, is not part of RCAs. Answer C is also incorrect, as there are almost always other factors that contributed to the error.

As a nurse manager of a medicine unit in an academic hospital, you're aware that your unit has a high rate of patient readmissions. In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days. After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent. Why might you consider collecting balancing measures? (A) To show that you met your aim (B) To make sure you are able to publish your study (C) To demonstrate to your hospital board that you were justified in using resources for this project (D) To make sure you did not unintentionally damage other aspects of the unit's work

(D) To make sure you did not unintentionally damage other aspects of the unit's work

You are working on shortening the time it takes patients with chest pain to get to the cardiac catheterization lab in your hospital. Your aim is to have 90 percent of patients brought to the lab within 45 minutes of arrival to the hospital. You decide to try a care protocol that another hospital in the area implemented with great success.After implementing the new protocol, you observe that patients are getting to the lab more quickly than before, but not as quickly as you had predicted. You examine the data and realize that there are really multiple issues delaying patients' arrival to the catheterization lab. Specifically, the emergency department needs to notify the lab staff in advance, but this communication rarely happens. Further, the schedule that the emergency department uses to contact the lab staff is riddled with errors. Based on the recommendations in this lesson, what should you do next? (A) Focus on fixing the schedule. (B) Discipline the emergency department staff who have failed to contact the catheterization lab in the past. (C) Focus on improving the communication between the emergency staff and the catheterization staff. (D) Work on improving both the schedule and communication at the same time.

(D) Work on improving both the schedule and communication at the same time.

When trying to improve a process, one reason to use PDSA cycles rather than a more traditional version of the scientific method (such as a randomized, controlled trial) is that: (A) PDSA cycles are easier to run with a large team of people. (B) The results of PDSA cycles are more generalizable than other methods. (C) PDSA cycles are simpler to use than other methods. (D) PDSA cycles provide a mechanism to adjust improvement ideas as the project progresses. (E) Both C and D

(E) Both C and D

One hospital CEO insists on including performance data in the hospital's annual report. "We do very well on most measures, except for one or two, but we put those in anyway," she says. "We want to hold ourselves accountable." Does this practice demonstrate effective or ineffective leadership? (A) Ineffective leadership: Because results are an important indication of leadership, publicly sharing poor results is an unwise practice. (B) Effective leadership: Being transparent, even about poor results, is a mark of a good leader. (C) Ineffective leadership: Leaders are people who have followers, and sharing poor results might cause the leader to lose some followers. (D) Effective leadership: It is good to share results in the annual report, but the leadership would be even more effective if it shared only the strongest results.

A medical unit in a hospital is in the midst of hiring some new physicians. During an orientation for new employees, a senior leader stands up and says, "We expect that the same rules apply to everyone on the unit, regardless of position." Which aspect of a culture of safety does this unit seem to value? (A) Psychological safety (B) Fairness (C) Transparency (D) None of these Good leaders know that leaders are highly visible — and they therefore set examples for others. A leader who seeks transparency in her followers must demonstrate the same quality herself.

The general surgery unit is working on reducing the number of catheter-associated urinary tract infections (UTIs) it causes. After some hard work, the unit has finally seen rates, which are reported monthly, come down for the first time by 20%. You are the Medical Director of the unit. Which of the following should you do now? (A) Declare victory and move on to the next project. (B) Keep working - it takes time to create lasting change. (C) Call the statistician to double-check the results. (D) Send an email to your boss telling him/her that the problem has been fixed.

Keep working - it takes time to create lasting change. It takes time to create lasting change. Although it might be tempting to declare victory the first time the numbers improve, that could be an aberration. To make sure the gains are sustained, the practitioners on the general surgery unit need to commit to the culture change and maintain the hard work. Rates should be monitored continuously to make sure the improvement is sustained.

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