Which of the following actions has the greatest impact in reducing harm?
a. Revising the patient safety evaluation tool
b. Improving interdisciplinary communication
c. Forming a performance improvement team
d. Increasing data collection frequency - ANSWER b.
Performance improvement teams are not always focused on reducing harm.
Balanced scorecards are useful because they:
a. Focus on the most significant strategic initiative
b. Evaluate the pros and cons of the governing body's priorities
c. Put strategy and vision at the center of an organization's effort
d. Concentrate on the performance of individual units - ANSWER c.
The balanced scorecard is a management framework that translates an organization's strate-
gic objectives into a set of performance measures that are measured, monitored, and
changed, If necessary, to ensure that organization's strategic goals are met.
Medication reconciliation is a process intended to
a. Identify and resolve discrepancies
b. Investigate further discrepancies
c. Increase use of electronic medication administration
d. Improve efficiency of medication administration - ANSWER a.
1
,A root cause analysis team examined a serious medication error and recommended changes.
Which of the following should be done next?
a. Random checks for compliance should be made by patient safety staff.
b. The Quality Council should review medication errors quarterly.
c. The process owner should implement and assess effectiveness.
d. Monthly reports should be sent to the regulatory body. - ANSWER c.
The recommended changes need to be assigned ownership.
The best way to evaluate the effectiveness of performance improvement training is through
a. Observed behavioral changes
b. Self-assessments
c. Participants' feedback
d. Post-test results - ANSWER a.
All of these are methods to evaluate effectiveness of performance improvement training,
but observed behavioral change is the best method as it demonstrates transfer of
knowledge into practice.
Based on the principles from the Institute for Healthcare Improvement (IHI), who has the ul-
timate responsibility for the effectiveness of quality improvement and patient safety within
an organization?
a. Quality improvement director
b. Medical director
c. CEO
d. Governing body - ANSWER d.
This is the expectation of TJC and CMS.
A serious event has occurred related to the timely notification of critical test results. The
root cause was traced to nursing difficulty with following the organizational policy. To pre-
vent a similar event from reoccurring, which of the following should be done next?
a. Refer the involved nurse to nursing peer review.
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, b. Educate nursing staff on the importance of timely notification of critical test results.
c. Review the policy with nursing representatives to identify ambiguities.
d. Continue to collect data as one event is insufficient to take action. - ANSWER c.
This step addresses the result of the root cause.
Facility A is investigating its medication administration time for a specific diagnosis. Evi-
dence-based guidelines indicate that administration of a particular drug within 30 minutes
significantly improves patient outcomes. The national average is 32 minutes. The average for
Facility B is 28 minutes. If the average for Facility A is 35 minutes, Facility A should
a. Determine whether its rate is within one standard deviation of the national average
b. Decrease its rate to meet the national average
c. Contact Facility B to determine its practices
d. Identify the average time of its competitors - ANSWER c.
Sharing best practices is encouraged for process improvement.
The leader of a pain management performance improvement team has asked the Quality
Council to disband the team. The most important factor for the Quality Council to assess is
a. The length of time the team has been together
b. How well the team met the intended outcome
c. The effectiveness of the team leader and facilitator
d. The amount of data the team has collected - ANSWER b.
When a team evaluating the use of restraints starts to discuss a liability claim related to a pa-
tient, the facilitator should
a. Redirect the team
b. Consult the risk manager
c. Request the medical record
d. Review team ground rules - ANSWER a.
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a. Revising the patient safety evaluation tool
b. Improving interdisciplinary communication
c. Forming a performance improvement team
d. Increasing data collection frequency - ANSWER b.
Performance improvement teams are not always focused on reducing harm.
Balanced scorecards are useful because they:
a. Focus on the most significant strategic initiative
b. Evaluate the pros and cons of the governing body's priorities
c. Put strategy and vision at the center of an organization's effort
d. Concentrate on the performance of individual units - ANSWER c.
The balanced scorecard is a management framework that translates an organization's strate-
gic objectives into a set of performance measures that are measured, monitored, and
changed, If necessary, to ensure that organization's strategic goals are met.
Medication reconciliation is a process intended to
a. Identify and resolve discrepancies
b. Investigate further discrepancies
c. Increase use of electronic medication administration
d. Improve efficiency of medication administration - ANSWER a.
1
,A root cause analysis team examined a serious medication error and recommended changes.
Which of the following should be done next?
a. Random checks for compliance should be made by patient safety staff.
b. The Quality Council should review medication errors quarterly.
c. The process owner should implement and assess effectiveness.
d. Monthly reports should be sent to the regulatory body. - ANSWER c.
The recommended changes need to be assigned ownership.
The best way to evaluate the effectiveness of performance improvement training is through
a. Observed behavioral changes
b. Self-assessments
c. Participants' feedback
d. Post-test results - ANSWER a.
All of these are methods to evaluate effectiveness of performance improvement training,
but observed behavioral change is the best method as it demonstrates transfer of
knowledge into practice.
Based on the principles from the Institute for Healthcare Improvement (IHI), who has the ul-
timate responsibility for the effectiveness of quality improvement and patient safety within
an organization?
a. Quality improvement director
b. Medical director
c. CEO
d. Governing body - ANSWER d.
This is the expectation of TJC and CMS.
A serious event has occurred related to the timely notification of critical test results. The
root cause was traced to nursing difficulty with following the organizational policy. To pre-
vent a similar event from reoccurring, which of the following should be done next?
a. Refer the involved nurse to nursing peer review.
2
, b. Educate nursing staff on the importance of timely notification of critical test results.
c. Review the policy with nursing representatives to identify ambiguities.
d. Continue to collect data as one event is insufficient to take action. - ANSWER c.
This step addresses the result of the root cause.
Facility A is investigating its medication administration time for a specific diagnosis. Evi-
dence-based guidelines indicate that administration of a particular drug within 30 minutes
significantly improves patient outcomes. The national average is 32 minutes. The average for
Facility B is 28 minutes. If the average for Facility A is 35 minutes, Facility A should
a. Determine whether its rate is within one standard deviation of the national average
b. Decrease its rate to meet the national average
c. Contact Facility B to determine its practices
d. Identify the average time of its competitors - ANSWER c.
Sharing best practices is encouraged for process improvement.
The leader of a pain management performance improvement team has asked the Quality
Council to disband the team. The most important factor for the Quality Council to assess is
a. The length of time the team has been together
b. How well the team met the intended outcome
c. The effectiveness of the team leader and facilitator
d. The amount of data the team has collected - ANSWER b.
When a team evaluating the use of restraints starts to discuss a liability claim related to a pa-
tient, the facilitator should
a. Redirect the team
b. Consult the risk manager
c. Request the medical record
d. Review team ground rules - ANSWER a.
3
