Safety Certification, National Patient Safety Goals,
Patient Safety and Risk Management Test Questions
And Answers Verified 100% Correct
unintended consequences of CPOE - 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) - 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 - 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 - 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 - ANSWER 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 - 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 - ANSWER 1. setting the stage
2. description or reactions
3. analysis
4. application
plus delta debriefing - 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 - ANSWER team evaluates if:
had clear communication
understanding of roles & responsibilities
maintained situational awareness
distributed workload
cross-monitoring (asked and offered help prn)
made, mitigated, or corrected errors
detecting errors and safety hazards - ANSWER goal to prospectively id
hazards before pt harmed and analyzing events that have occurred to id
and address underlying systems flaws
, FMEA - ANSWER Failure Mode and Effects Analysis
1. identify 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 - ANSWER structured what-if technique
perceived safety problems can be detected through - ANSWER
safety culture surveys
executive walk rounds
techniques to retrospectively identify safety hazards - 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)
hazard detection methods - ANSWER voluntary error reports
malpractice claims pt complaints executive walk rounds
risk mgmt. database
framing effects - ANSWER dx decision making unduly biased by subtle
cues and collateral information (addicted pt with abd pain tx for withdrawal
but had bowel perf)
blind obedience - ANSWER undue reliance on test results or
expert opinion (false neg rapid Strept test)