CPHRM Old CH2

High-reliability organizations:

A key characteristic of a high-reliability organization is a reluctance to simplify. This means that the organization utilizes detailed processes for each key function and strives to include as many steps as possible to decrease the possibility of errors.

A Failure mode, effects and criticality analysis (FMECA)) is a process used to investigate serious adverse events in an effort to identify the active and latent causes of the event.

Nurse Johnson was administering medications to the two patients in room 236 using the bar-coding system. According to the facility’s written procedure, the nurse was to administer each patient’s medication separately. She was to scan the medication, then scan the patient’s bar code, check for any error alerts, and then administer the medication if no alerts appeared. The nurses complained that going out to the medication cart between patients was time-consuming. To save time, Nurse Johnson habitually scanned the medication and the patient’s bar codes while the medication was being administered. On this day, after giving patient A his medication, he immediately became severely short of breath, signaling an allergic reaction, and respiratory support was required. Following an investigation it was determined that Nurse Johnson had given patient A the medication for patient B and an error alert would have activated in the bar-coding system. Nurse Johnson’s behavior is an example of:

Mrs. Cobb was admitted for surgery on her right leg. At the conclusion of the surgery, she awoke to learn that the wrong leg had been operated upon. An investigation revealed that the pre-operative nurse had performed the site marking incorrectly and had placed the X-rays in the OR suite facing backward. The root cause analysis team identified that failure to have surgeons routinely participate in the site-marking process, with confirmation by the patient, was a participatory cause of the incident. This failure identified by the root cause analysis team is an example of:

Select the answer that best identifies those organizations that are key influencers in the field of patient safety:

Taxonomy is a necessary and important aspect of patient safety because:

The Emergency Department is a high risk area for which of the following reasons?

1. Brief patient contact
2. Lack of familiarity with the patient’s medical history
3. Use of nurse practitioners and physician’s assistants
4. Language and cultural barriers

Which of the following statements regarding the use of restraints are TRUE?

1. Wrist or vest devices can be considered restraints
2. Locked seclusion is considered a form of physical restraint
3. Medication used to significantly alter a patient’s behavior on an emergency basis is considered a form of chemical restraint
4. Voluntary use by a patient of an unlocked “quiet room” is NOT considered a form of physical restraint

The legal theory res ipsa loquitur would most likely apply to which of the following scenarios?

 Behavioral health patients may be at high risk for abuse. Which of the following statements regarding the risk of abuse of behavioral health patients are true?

1. Pediatric, adolescent, and geriatric behavioral health patients are particularly vulnerable populations that may be at even greater risk for abuse
2. A crucial abuse prevention strategy is to require that all behavioral health workers undergo reference checks and criminal background checks before they are allowed to work with patients
3. The organization must have a zero tolerance philosophy regarding any form of abuse including physical, sexual, and emotional abuse
4. Behavioral health patients may be confused and/or disoriented, and staff should be given “the benefit of the doubt” and be allowed to continue working while a patient’s allegation of abuse is being investigated

A study published in 1999 revealed that approximately 44,000 to 98,000 people die each year in US hospitals due to preventable medical errors. The entity that directly initiated the study was:

To maintain confidentiality of an incident report:

1. Send the incident report directly to risk management
2. Never make the incident report part of the medical record
3. Never mention the facts of the incident in the medical record
4. Maintain the original in the risk management office and a copy in the originating department

If a practitioner requests a telemedicine consult with another practitioner in a different state, the consultant:

For more than 20 years, which of the following high-risk clinical specialties has led, or been dose to the top of, severity statistics for liability claims?

A surgeon performs a hysterectomy on a 25-year-old female due to an abnormal Pap smear result obtained as an outpatient in the physician’s office. The final pathology report on the uterus states the uterus contains only benign inflammation with no cancerous cells present. The case is referred to the Obstetrics department, where the actions of the surgeon are discussed at length. It is concluded that the surgeon acted in good faith based on the incorrect Pap smear from an independent laboratory. The patient sues the obstetrician and the hospital, and seeks to obtain copies of the minutes and any other documents related to the Obstetrics department meeting. Which of the following is true?

Safety culture surveys are intended to assess the organizational and unit-level attitudes regarding patient safety. Survey results can reveal differences in perception of safety between types of staff (such as MD and RN) and between departments or teams. They can be used to identify priorities for improvement and to help create a performance improvement action plan.