According to WHO, in developed countries worldwide, what is the approximate likelihood that a hospitalized patient will be harmed while receiving care?
a) <1%
b) 10%
c) 50%
d) >75%
b) 10%
Since the publication of To Err Is Human in 1999, the health care industry overall has seen which of the following improvements?
a) A 75 percent reduction in preventable medical errors
b) Stronger repercussions for providers who commit preventable medical
c) wider awareness that preventable errors are a problem
Safety has been called a "dynamic non-event" because when humans are in a potentially hazardous environment:
a) It is natural to establish and follow safe practices
b) It requires the same kind of thinking that causes problems to set them right
c) It take
c) it takes significant work to ensure nothing bad happens
To prevent this type of error from recurring in this unit, which of the following is MOST important?
a) clear medical guidelines for fluid replacement in patients of all ages
b) An improved culture of safety and teamwork
c) Closer supervision of residents
b) an improved culture of safety and teamwork
Who is likely to be negatively affected by this medical error?
a) the patient and his family
b) James (the first-year surgery resident)
c) Maria (the nurse on the unit)
d) All of the above
d) All of the above
What is most likely to happen if a health system punishes an individual for an unintended error that was the result of a system problem?
a) Staff may be less likely to talk openly about and learn from errors
b) staff will be more careful and errors will d
d) A and C
Which of the following statements is true about blame and punishment of individuals for making errors?
a) they can undo the error
b) they can prevent the error from happening again
c) they can be appropriate responses if that individual intentionally caus
c) they can be appropriate responses if that individual intentionally caused harm
A colleague accesses and delivers a medication, believing it is the correct one. Unfortunately, it isn't - it is another medication in a similar vial. Which of the following is the best way to address his error?
a) Ask him to take a couple of weeks off wi
d) investigate whether others find the vials confusing and consider making a change to how they are packaged or accessed
When an error occurs, which of the following is a productive response?
a) Interview all participants in the process to determine what happened
b) Suspend the licenses of everyone involved
c) Determine if reasonable changes can be made to prevent the same
d) A and C
Which of the following situations seems to warrant punitive action?
a) A colleague routinely refuses to perform a mandatory safety process
b) A colleague is involved in the same type of error more than once
c) A colleague makes a mistake because she is di
a) A colleague routinely refuses to perform a mandatory safety process
Which of these is a behavior providers should adopt to improve patient safety?
a) develop ways to work around broken systems
b) ignore patients' individual preferences when they disagree with "best practice"
c) Follow written safety protocols, even if the
c) Follow written safety protocols, even if they slow you down
What would be the MOST appropriate way for the nurse to respond?
a) call the physician at home and warn her to stop abusing prescription medication
b) refuse to work with that physician in the future
c) Start logging the suspicious occurrences as he sees
d) Talk to the medical director now, in confidence
When it comes to self-care, which of the following statements is true?
a) if you're especially stressed because of a divorce, it may adversely affect your performance
b) lack of sleep can be similar to being drunk
c) spending quality time with friends can
d) all of the above
Which of the following critical behavior(s) did Janet violate?
a) follow safety protocols
b) speak up when you have concerns
c) take care of yourself
d) A and C
d) A and C
Which of the following techniques represent best practice for communicating with patients and families?
a) listen to and honor patient and family perspectives and choices
b) identify a patient's and family's knowledge, values, beliefs, and cultural backgr
d) all of the above
Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for "units"), and it looks more like an extra
a) long work schedule
Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for "units"), and it looks more like an extra
c) develop a system that prevents messy handwriting from causing miscommunication that leads to error
Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for "units"), and it looks more like an extra
a) defects in the design and organization of process and systems
Two women � one named Camilla Tyler, the other named Camilla Taylor � arrive at a particularly busy emergency department at about the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an antibiotic. The doctor orders the medications, but mixes u
b) the nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor
Two women � one named Camilla Tyler, the other named Camilla Taylor � arrive at a particularly busy emergency department at about the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an antibiotic. The doctor orders the medications, but mixes u
c) the forms are completed by hand at the same time for different patients
According to James Reason, by definition an "unsafe act" always includes:
a) a potential hazard
b) harm to one or more patients
c) one or more mistakes
d) all of the above
a) a potential hazard
Anita, a nurse practitioner, is seeing Mr. Drummond in clinic. Mr. Drummond is a 57-year-old man with diabetes and chronic kidney disease. Having kept up on the literature, Anita is aware that tightly controlling his diabetes can slow the progression of h
a) lapse
Roger, a pharmacist in a hospital, is working in the discharge pharmacy filling medications for patients who are going home. He sees a prescription for ciprofloxacin, an antibiotic, and he asks his pharmacy technician Mike to fill it quickly, as the patie
d) violation
Roger, a pharmacist in a hospital, is working in the discharge pharmacy filling medications for patients who are going home. He sees a prescription for ciprofloxacin, an antibiotic, and he asks his pharmacy technician Mike to fill it quickly, as the patie
b) it allows us to change the conditions under which humans work
At University Hospital, the rate of Clostridium Difficile colitis has doubled during the past year. After reviewing the data, the hospital's senior leaders conclude that this is due to poor hand hygiene on the part of the staff, even though they have a cl
c) lapse
What intervention helped prove that catheter-associated bloodstream infections (CLABSIs) were preventable consequences of care?
a) a new guideline that required all staff to wash their hands with alcohol and soap before inserting a catheter
b) a checklist
b) a checklist of evidence-based practices applied consistently and collectively every time a catheter is used
What is one reason that patients safety has shifted to work on reducing harm in addition to preventing errors?
a) human error has become less common in health care
b) harm is more preventable than providers once thought
c) identifying errors rarely leads
b) harm is more preventable than providers once thought
Which of the following is included in the IHI Global Trigger Tool definition of harm?
a) psychological harm such as a miscommunication about a diagnosis
b) financial harm from expensive medical bills
c) the absence of needed care that contributes to harm,
d) physical injury caused by medical care that triggers additional care
The Swiss cheese model of harm illustrates what important concept in patient safety?
a) unsafe acts (including errors and violations) are the most important cause of harm to patients
b) both latent unsafe conditions and active failures (unsafe acts) contr
d) B and C
Why do some patient safety leaders such as Dr. David Bates believe the definition of harm should be broader than the definition in the IHI Global Trigger Tool?
a) because health care systems have eliminated all harms included in the current definition
b)
c) because health care systems should work to prevent more types of harm than the current definition includes
Human factor is the study of:
a) interactions among humans
b) interactions between humans and machines
c) interactions between humans and the environment
d) all of the above
d) all of the above
Which of the following is an example of unconscious processing by the train?
a) optical illusions
b) skipping a step on a checklist to save time
c) mistaking one drug for another because of look-alike packages
d) A and C
d) A and C
When attempting to decrease the risk of error, it's important to use human factors principles because:
a) if you understand the factors that cause people to make mistakes, you can hire safer providers
b) if you understand human factors principles, you can
c) if you understand the factors that affect human performance on critical tasks, you can design a safer system
You visit the local convenience store looking for a refreshing drink on a pleasant day. You know that you want a new type of cola beverage you've heard advertised on the radio, and reach into the refrigerator for what you think is the caffeine-free versio
a) look-alike cans/labels
At the end of a double shift, an experienced nurse with an excellent track record gives medication to the wrong patient. Based on human factors principles, what would you guess the biggest contributor to this error?
a) the nurse was prone to error because
a) the nurse was prone to error because she was tired
Which of the following is a basic strategy for minimizing the opportunity for error in a process?
a) reducing reliance on technology
b) standardizing how the process is completed
c) trying harder to perform the process correctly
d) A and C
b) standardizing how the process is completed
Which of the following statements about redundancies within processes is always true?
a) they are needlessly insufficient
b) they remove the opportunity for error
c) they require two people to do the work of one
d) none of the above
d) none of the above
Your hospital is implementing an electronic health record (EHR) and is teaching all staff how to use it. As you go through the EHR training, you notice that it takes five clicks to bring up the vital signs for a patient. In the past, when you wanted to se
a) it needs to be simplified
Your hospital is implementing an electronic health record (EHR) and is teaching all staff how to use it. As you go through the EHR training, you notice that it takes five clicks to bring up the vital signs for a patient. In the past, when you wanted to se
d) avoiding reliance on memory
Your hospital is implementing an electronic health record (EHR) and is teaching all staff how to use it. As you go through the EHR training, you notice that it takes five clicks to bring up the vital signs for a patient. In the past, when you wanted to se
a) a forcing function
You're working in an outpatient clinic that recently started using an electronic health record (EHR). You are entering a prescription for an antibiotic into the EHR to treat Mrs. Jones's urinary tract infection. As you enter the order, a warning screen po
d) all of the above
Which of the following statements about computerized prescriber order entry systems (CPOEs) is true?
a) several studies have disputed the claim that they reduce errors
b) they eliminate the possibility for error by eliminating the reliance on human memory
a) several studies have disputed the claim that they reduce errors
Which of the following is the best example of using technology to improve safety and prevent errors?
a) providing inpatients with electronic tablets so that they can keep in better touch with the outside world
b) giving nursing assistants electronic table
b) giving nursing assistants electronic tablets to ensure there's no delay in recording patients' vital signs
effective ways for addressing defects in the human-technology interface include:
a) providing in-person user training on using the technology
b) testing the technology in real-world situations
c) encouraging users to find workarounds
d) all of the above
b) testing the technology in real-world situations
You're caring for a patient with diabetes who was admitted to your hospital with an elevated blood glucose level. She is on an insulin pump that is programmed to deliver one unit of insulin per hour through her intravenous (IV) line. How does this technol
c) the pump helps automate a complex care process
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 for day-to-day
c) effective c
c) effective communication techniques
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
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 clin
c) the team routinely takes a moment to discuss the plan and voice concerns before doing a procedure
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 w
a) effective teams reduce the risk of errors by providing a "safety net" for individual caregivers
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
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
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
d) A and B
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
c) so that the patient does not experience an adverse event
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
b) "i am concerned there is a safety issue here.
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
a) "thanks! i'll tell your supervisor that you helped me today
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 my staff feel comfortable reporting errors only
c) a place where all staff can talk freely about safety problems without fear
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
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 f
b) provided a read back
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 invo
d) conduct a debriefing
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 invo
d) implement the use of critical language in the ICU
Effect 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
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 th
c) care for the patient, communicate with the patient, report to all appropriate parties, check the medical record
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
d) A and B
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
b) open communication with patients can assuage caregivers' feelings of guilt
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) the lack empathy for patients and families
c) they fear disapproval
d) all
c) they fear disapproval
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)
a) speak clearly and directly
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 th
c) care for the patient, communicate with the patient, report to all appropriate parties, check the medical record
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 si
a) "how is your pain?
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 si
b) an apology is needed to maintain provider-patient trust
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 wh
d) reparation
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 er
c) say something like, "there is just no excuse for what happened.
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 manager who become involved in the error
d) other patients who might experience t
b) the caregivers involved in the error
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 coupl
a) she should speak calmly with you about what happened and how you're feeling about it
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 coupl
b) offering support helps prevent depression or decreased job satisfaction
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 coupl
b) "the HUC almost killed someone yesterday because she doesn't pay enough attention
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 relation department
b) the employee assistance
Why should a RCA be conducted by a team member rather than 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 pro
a) understanding what led to an error requires diverse perspectives
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
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 pr
a) team factors, institutional context, and organizational factors
which of the following is an example of the type of casual 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 unqualifie
d) the patient was unattended for 30 minutes because the nurse was busy caring for other patients, and this contributed to the outcome
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
root cause analyses can be useful in health care because:
a) they can 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
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 th
c) the hierarchy in the operating room had a negative effect upon communication
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 sur
d) organizational and management factors
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 ca
c) a social worker catches a patient who is falling out of bed
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
a) use categories to organize events that led to errors
Quinn is a 3 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 done of heparin. Although he suffers no permanent injuries, the leadership
c) create a team of members who fulfill several roles
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 cann
c) make sure the team has time and resources to conduct the RCA, including access to advisors when necessary
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 casual statements using Charles Vincent's framework
d) review anonymous opi
b) review Quinn's medical records and interview providers
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
a) understanding what led to an error requires diverse perspectives
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
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 pr
a) team factors, institutional context, and organizational factors
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 pr
d) the patient was unattended for 30 minutes because the nurse was busy caring for other patients, and this contributed to the outcome
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
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 call nurse has reached the patients with their results, so that 99% of patients receive ca
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
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
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
a) a clear description of what happened, root causes, and recommendations for prevention. team members and methods should be included
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
c) practice leadership and the hospital leadership
What are the 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 condu
d) people participating in the RCA may not be familiar with how to conduct them, and they do not always produce actionable recommendations
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 st
a) the medical resident caring for her did not know the appropriate antibiotics for this type of infection
according to the world health organization (WHO) how could at least half a million death due to surgical error be prevented every year?
a) by developing better surgical technology
b) by implementing systematic changes in operating rooms
c) by inflicting s
b) by implementing systematic changes in operating rooms
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 systematic problems in t
d) A and B
what did Paul Levy do after handling the immediate fallout from the wrong-site surgery?
a)he proposed creating an institutional video about the experience that would be viewed at meeting and conferences
b) he explained the event and the hospital's respons
d) all of the above
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
d) circumstances could exist where the providers were to blame for the error
Ben, a 36 year-old patient with Type 1 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 placed on the left arm, bu
a)the mistake should be communicate to ben and the hospital's administrators
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 demonstrat
b) effective leadership: being transparent, even about poor results, is a mark of a good leader
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 phy
c) fairness
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 phy
b) writing a letter of commendation for his file
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' a
d) it allows people to learn from mistakes and near-misses, reducing the chances of further errors
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
b) fairness
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
a) the lack of a shared plan for patients with chest pain resulted in a failure to act quickly
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
a) the unit's culture doesn't effectively promote psychological safety
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,
a) develop a plan to ensure that everyone in the department is clear about the problem
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,
c) implement standardized procedures to help enable workers to speak up
which of the following is an example of transparency?
a) firing the physician with the lowest patient satisfaction rating each year
b) discussing a time when you made an error similar to one that just occurred, and explaining what you learned
c) making su
b) discussing a time when you made an error similar to one that just occurred, and explaining what you learned