Certified Professional in Patient Safety 2022 QUESTIONS AND ANSWERS| GRADED A

Certified Professional in Patient Safety iatrogenesis Correct Answer: Greek for originating from a physician preventable adverse events Correct Answer: those that occurred due to error or failure to apply an accepted strategy for prevention Ameliorable adverse event Correct Answer: events that, while not preventable, could have been less harmful if care had been different adverse events due to negligence Correct Answer: those that occurred due to care that falls below the standards expected of clinicians in the community near miss Correct Answer: an unsafe situation that is indistinguishable from a preventable adverse event except for the outcome - exposed but does not experience harm either through luck or early detection error Correct Answer: broader term referring to any act of commission or omission that exposes patients to a potentially hazardous situation adverse event Correct Answer: An injury caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced at disability at the time of discharge, or both commision Correct Answer: doing something wrong omission Correct Answer: failing to do the right thing CPOE Correct Answer: Computerized Provider Order Entry 2009 HITECH Act and meaningful use program computer alerts three main findings Correct Answer: 1. modestly effective at best 2. alert fatigue is common 3. fatigue increases with exposure and heavier use of CPOE systems minimize alert fatigue Correct Answer: 1. increase alert specificity to reduce inconsequential alerts 2. tier alerts according to severity 3. make only high level/severe alerts interruptive 4. use human factors principles three concepts that influence safety in ambulatory care Correct Answer: 1. role of pt and caregiver behaviors 2. role of provider-pt interactions 3. role of community and health system Medical Office Survey on Pt Safety Culture Correct Answer: designed to assess safety culture in amb care and data is available from AHRQ Pt Engagement Correct Answer: 1. ed pt about their illness and medications with pt demonstrating understanding "teach back" 2. empowering to act as a safety double check checklist Correct Answer: Algorithmic listing of actions to be performed for a given clinical procedure designed to ensure that no matter how often performed by a given clinician, no step will be forgotten reduce risk of slips consensus of required behaviors slips Correct Answer: failure of schematic (autopilot) behaviors lapses in concentration, distractions, or fatigue mistake Correct Answer: failures in attentional behavior lack of experience or insufficient training Situational Awareness Correct Answer: the ability to access and track relevant to the task, comprehend the data, forecast what may happened based on the data, and formulate an appropriate plan in response situational awareness cannot be achieved without Correct Answer: clear and high-quality communication between all providers most common root cause of sentinel events Correct Answer: communication elements the affect communication Correct Answer: 1. rigid hierarchies 2. overtly disruptive and unprofessional behavior 3. nonverbal cues 4. interpersonal relations 5. group dynamics communication tools Correct Answer: read-back protocols SBAR teamwork training process for prescribing and adm meds Correct Answer: 1. order 2. Transcribing 3. dispensing 4. administration 90% errors occur at ordering (48%) or transcribing thus CPOE prevent CDSS Correct Answer: Clinical Decision Support System assist healthcare providers in the actual diagnosis and treatment of patients, analyze data from clinical information systems avoids commission and omission errors unintended consequences of CPOE Correct Answer: 1. more or new work for clinicians 2. unfavorable workflow 3. never-ending system demands 4. persistence of paper orders 5. changes in communication patterns and practices 6. neg towards new technology 7. new types of errors 8. change in power structure, org culture , or professional roles High Reliability Organizations (HROs) Correct Answer: persistent mindfulness with in an organization cultivate resilience by relentlessly prioritizing safety over other performance pressures consistently minimize adverse events despite carrying out intrinsically complex and hazardous work safety is emergent vs. static commitment to safety at all levels HRO key features Correct Answer: 1. know high-risk nature of activities and determine to have consistent safe operations 2. blame-free 3. collaboration across ranks and disciplines 4. commitment of resources to address safety concerns Patient Safety Culture Surveys and Safety Attitudes Questionnaire Correct Answer: ask providers to rate the safety culture in their units and org as a whole poor perceived safety culture= increased error rates just culture Correct Answer: id and addressing systems issues that lead individual to engage in unsafe behaviors while maintain accountability human error (slip) at risk behavior (short cuts) reckless behavior (ignoring required safety steps) Debriefing Correct Answer: dialogue to learn from defects and improve performance through goal discussion, reflection to incorporate improvement or discover opportunities in future performance simulation real-life emergency responses teamSTEPPS Components of debriefing Correct Answer: 1. setting the stage 2. description or reactions 3. analysis 4. application plus delta debriefing Correct Answer: 1. What went well? 2. What did not go well? 3. what can we do differently or what needs to change to improve care? debriefing framework Correct Answer: team evaluates if: had clear communication understanding of roles & responsibilities maintained sit awareness distributed workload cross-monitoring (asked and offered help prn) made, mitigated, or corrected errors detecting errors and safety hazards Correct Answer: goal to prospectively id hazards before pt harmed and analyzing events that have occurred to id and address underlying systems flaws FMEA Correct Answer: Failure Mode and Effects Analysis 1. id all process steps "process mapping" 2. how each step can go wrong "failure modes" 3. impact of each error 4. likelihood of process failure 5. chance of detecting failure 6. impact of error SWIFT Correct Answer: structured what-if technique perceived safety problems can be detected through Correct Answer: safety culture surveys executive walk rounds techniques to retrospectively id safety hazards Correct Answer: 1. screen larger datasets for evidence of preventable adverse events that merit further investigation (trigger tools, patient safety indicators) 2. analyze individual cases of adverse events (RCA, mortality reviews, in-depth investigation) Patient Safety and Quality Improvement Act Correct Answer: Jan 2009 confidential and privilege protections for pt safety info when HCP work with Patient Safety Organizations hazard detection methods Correct Answer: voluntary error reports malpractice claims pt complaints executive walk rounds risk mgmt. database per Harvard Medical Practice Study, what % of errors were diagnostic Correct Answer: 17% 9% were undetected while pt was alive heuristics Correct Answer: Mental shortcuts or "rules of thumb" that often lead to a solution (but not always) availability heuristic Correct Answer: dx of current pt biased by experience with past cases (crushing chest pain=MI) anchoring heuristic Correct Answer: relying on initial dx impression despite subsequent info to the contrary (BC with corynebacterium txed as contaminant when endocarditis)