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Which of the following is the best tool to begin an investigation into the causes of laboratory labeling errors?
A medication error occurred and resulted in a severe adverse outcome. In addition to informing the patient and/or family, a healthcare quality professional should
When errors are discovered, staff and supervisors best demonstrate a culture of safety by
A root cause analysis team examined a serious medication error and recommended changes. Which of the following should be done next?
Minimizing the chances for an adverse event to reoccur includes determining the primary contributing factor by using
Root cause analysis following a sentinel event will probably require a
A healthcare quality professional is asked to investigate an unusually high rate of healthcare-associated infections in the last month. In trying to determine the cause of this sudden increase in the healthcare-associated infection rate, she categorized The possible root causes. Which of the following was NOT a category of possible root causes?
The second sponge count at the end of a hernia repair operation on an obese patient was incorrect. This was confirmed by repeat sponge counts, and the surgeon eventually located and retrieved the missing sponge. The patient’s recovery was uneventful. The healthcare professional should
In an acute care facility, the delivery times of x-ray results were higher on Saturday and Sunday, compared with the other days of the week. What should the management do next to improve weekend performance?
A 300-bed multidisciplinary acute care hospital has consulted a healthcare quality consultant to assist in the investigation of a series of sentinel events that have occurred in the past 6 months. The consultant should expect to find all of the following except:
To be useful in preventing future error, a Root Cause Analysis (RCA) should be performed
After significant unexpected event, an intensive analysis is performed to:
A patient in an acute psychiatric unit committed suicide by hanging himself with his shoelaces. To prevent this from occurring again, the most appropriate action is to institute
Informed consent for hip surgery was obtained and documented for an elderly patient. In the recovery room, a nurse discovered the wrong hip had been replaced. A healthcare quality professional should
When conducting a sentinel event review, a root cause analysis