2026/2027 COMPLETE QUESTIONS
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1. In preparation for new antimicrobial stewardship regulatory requirements, a
hospital is creating an antimicrobial stewardship committee. What should be
the first step in supporting this new patient safety initiative?
A. Reach out to subject matter experts to gain insight on different
compliance issues.
B. Work with information technology (IT) to build antibiotic indication
and time-out screens.
C. Partner with key stakeholders to perform a gap analysis of current
state to ideal state.
D. Review the past year's data to identify the most commonly grown
pathogens. - ANSWER ✔ C. Partner with key stakeholders to perform
a gap analysis of current state to ideal state.
2. A new Cath Lab is under construction in your hospital, and the medical
director contacts you to express concerns related to the transport of patients
from the Cath lab to the ICU. You agree to assist in the design of a failure
mode and effects analysis (FMEA).
Components of the FMEA will include:
A. Assembling a multidisciplinary team whose members will brainstorm
potential failures
B. Listing potential root causes of adverse events in the current Cath lab
C. Conducting the Five Whys exercise to figure out what could go wrong
, D. Asking the medical director to participate in leadership rounds in the
current Cath lab to identify potential safety risks - ANSWER ✔ A.
Assembling a multidisciplinary team whose members will brainstorm
potential failures
Assembling a multidisciplinary team is the first step in facilitating your
FMEA. Five Whys would be done as part of the FMEA, but this will occur
downstream, after potential failures are identified.
3. A hospital board wants to know how its safety performance in central line-
associated blood stream infections (CLABSIs) compares to that of other
hospitals in their region. Which data display would best inform them for that
decision?
A. A written report summarizing the current CLABSI prevention
protocols of each hospital in the region
B. A table indicating the CLABSI infection rates of all hospitals in the
region relative to the National Healthcare Safety Network benchmark
for CLABSI infections for the past two years
C. Control charts of overall infection rate by quarter for the past two
years for each hospital in the region
D. A table showing the number of CLABSI infections in each hospital in
the region by quarter for the past two years - ANSWER ✔ B. A table
indicating the CLABSI infection rates of all hospitals in the region
relative to the National Healthcare Safety Network benchmark for
CLABSI infections for the past two years
The correct answer is a table indicating the CLABSI infection rates of all
hospitals in the region relative to the National Healthcare Safety Network
benchmark for CLABSI infections for the past two years.In regard to the
other answer options: Reporting an overall infection rate does not tease out
CLABSI infections specifically. Written descriptions of protocols may not
, include performance data and would be harder to digest and find comparable
information to guide decision making. Counts of CLABSI infections alone
would not communicate enough information for decision making. Large
hospitals may have more infections than smaller hospitals because of their
size or patient acuity levels, so looking at rate would make performance
more comparable across hospitals.
4. Health Plan Employer Data and Information Set (HEDIS) - ANSWER ✔
performance measurement tool designed to help purchasers and consumers
evaluate managed care plans and to hold plans accountable for the quality of
their services
5. peer review organizations (PROs) - ANSWER ✔ Groups of medical
reviewers contracted by the Centers for Medicare and Medicaid Services
(CMS) to ensure quality control and the medical necessity of services
provided by a facility.
1. conduct cooperative quality improvement projects in partnership with other
quality-focused organizations.
2. conduct mandatory case review in response to beneficiary complaints, as
well as educational and outreach activities
3. oversee program integrity by ensuring that Medicare pays only for medically
necessary services
6. Attention to physical comfort - ANSWER ✔ timely, tailored, and expert
management of such symptoms.
7. A vaginal sponge left in a patient was discovered four days after the patient
was discharged from the hospital. Investigation revealed the procedure the
surgical team applied for counting sponges was inconsistent with the
facility's sponge count policy. This inconsistency had developed over a
, period of time, until staff could not state what the correct counting procedure
should be.
Which of the following concepts best explains what happened?
A.) Normalized deviance
B.) Malicious intent
C.) Workarounds
D.) Checklist fatigue - ANSWER ✔ A.) Normalized deviance
Normalized deviance refers to the phenomena in which workarounds
become accepted as the norm. (Workarounds are deviations from the
standard process that usually happen because the process is in some way
flawed, e.g., in this case, maybe two people were required to count but there
weren't always two people available.) Malicious intent is highly unlikely to
be the cause here. Checklist fatigue may lead to workarounds, but that does
not appear to be what happened here.
8. The requirement to perform manual independent double checks (IDCs) to
reduce errors in the administration of high-alert medications is common in
US hospitals. The Institute for Safe Medication Practices (ISMP)
recommends that IDC be used judiciously and for only very selective tasks,
not for all high-alert medications.
The rationale for ISMP's recommendation is:
A.) Given the workload requirements in today's hospitals, staff
members do not have adequate time to perform IDC for all
high-alert medications.
B.) Research has demonstrated that IDCs are not effective.
C.) Hospitals have reversal agents available to treat most
accidental medication overdose