Patient Safety 4

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Questions and Answers

Which metric is used to measure how well staff are informed about errors in hospitals?

Response to error

Organizational learning-continuous improvement

Communication about error (correct)

Communication openness

What aspect of patient safety culture emphasizes the importance of enough staffing levels and reasonable work pace?

Hospital management support for patient safety

Teamwork

Staffing and work pace (correct)

Handoffs and information exchange

What report evaluates medical errors and patient safety issues across various healthcare settings?

Patient Safety Culture Report (correct)

Validated Provider Survey

Annual Benchmark Report

Quality Improvement Report

Which category focuses on the actions taken by supervisors regarding patient safety improvements?

Supervisor, manager, or clinical leader support for patient safety Signup and view all the answers

In the context of patient safety culture surveys, what is the significance of organizational learning-continuous improvement?

To enhance work process reviews and adjustments Signup and view all the answers

How many items are included in the measure for communication openness?

3 Signup and view all the answers

What aspect of patient safety addresses the transfer of important patient care information?

Handoffs and information exchange Signup and view all the answers

Which measure assesses the fairness of treatment towards staff making mistakes?

Response to error Signup and view all the answers

What is the total number of items measuring the composite of teamwork in patient safety culture?

3 Signup and view all the answers

Which area of patient safety culture reflects the leadership's commitment to prioritizing safety?

Hospital management support for patient safety Signup and view all the answers

What is a key element of the TRIO program aimed at developing a safety culture in healthcare organizations?

In-depth assessments through structured surveys Signup and view all the answers

Which survey tool assesses a variety of healthcare management aspects, including medication safety and patient education?

MGMA Practice Profile Survey Signup and view all the answers

What strategy can be employed to sustain improvements in patient safety according to the TRIO program?

Incorporating a control plan Signup and view all the answers

According to the information, which of the following practices may reduce medical errors?

Automation of standardized processes Signup and view all the answers

In the 2019 and 2021 SOPS Hospital Survey data, which area showed a slight decrease in percentage?

Supervisor/Manager Expectations and Actions Promoting Patient Safety Signup and view all the answers

What is a primary goal of establishing a learning organization in healthcare?

To achieve continuous dynamic learning Signup and view all the answers

Which of the following is NOT a key step in creating a learning infrastructure according to AHRQ?

Establishing rigid processes to prevent outside opinions Signup and view all the answers

What aspect should healthcare quality professionals focus on when creating a sustainable learning infrastructure?

Developing performance excellence in safety processes Signup and view all the answers

Which element is essential for fostering a culture of safety within a learning organization?

Individual commitment to lifelong learning Signup and view all the answers

Which describes the role of AHRQ in supporting healthcare learning?

Offering free continuing education and toolkits Signup and view all the answers

What is an expected outcome of leveraging learning from other organizations that encountered errors?

To identify contributing factors and mitigation strategies Signup and view all the answers

A competency-based development plan in healthcare should primarily focus on:

Individual and team clinical and interpersonal skill development Signup and view all the answers

Which characteristic is essential for a learning organization aimed at continuous improvement?

Cultivating systems thinking in all levels Signup and view all the answers

Which of the following actions supports the development of a culture of patient safety?

Fostering open communication and teamwork Signup and view all the answers

What is a significant focus of lifelong learning in a healthcare setting?

Improving communication and teamwork skills Signup and view all the answers

What component of the learning system emphasizes the importance of negotiation and compromise to enhance healthcare delivery?

Negotiation Signup and view all the answers

Which of the following components targets the ongoing development of knowledge and skills among healthcare providers?

Continuous Learning Signup and view all the answers

In TeamSTEPPS, which tool is primarily focused on ensuring that critical information is conveyed clearly during communication?

Situation Background Assessment Recommendation Signup and view all the answers

Which aspect of the learning system framework emphasizes the role that team members' safety and wellbeing play in healthcare delivery?

Psychological Safety Signup and view all the answers

What is the primary goal of TeamSTEPPS as it relates to healthcare system performance?

Improve teamwork and prevent system errors Signup and view all the answers

Which component within the framework encourages openness and honesty in communication across the healthcare system?

Transparency Signup and view all the answers

Which of the following is considered a key outcome of mutual trust established within a TeamSTEPPS framework?

Higher patient satisfaction rates Signup and view all the answers

What is a major characteristic of the 'Improvement & Measurement' component of the learning system?

Continuous assessment of health outcomes and practices Signup and view all the answers

What is the primary benefit of effective communication among team members in a healthcare setting?

It aims for a higher-performing team with clear goals. Signup and view all the answers

Which of the following best describes the mission of the ECRI Institute?

To apply scientific research to improve patient care. Signup and view all the answers

What type of courses does the Open School offered by the Institute for Healthcare Improvement cover?

Various quality improvement and patient safety topics. Signup and view all the answers

What is one of the key focus areas of the Partnership for Health IT Patient Safety?

Identifying and addressing harm related to health IT. Signup and view all the answers

Which resource provided by ECRI is valuable for understanding medical device safety post-implantation?

Medical Device Material Safety Summaries. Signup and view all the answers

In the context of TeamSTEPPS, what does the emphasis on workload management primarily address?

Achieving balance during high-stress or workload periods. Signup and view all the answers

Which course topic covers analyzing the factors leading to errors in healthcare?

From Error to Harm. Signup and view all the answers

What is one expected outcome of fostering a culture of safety within a healthcare organization?

Increased transparency and reporting of errors. Signup and view all the answers

What is the primary initiative of the National Patient Safety Foundation since its inception in 1997?

Preventing harm in healthcare Signup and view all the answers

Which organization provides practical recommendations specifically aimed at preventing medication errors?

Institute for Safe Medication Practices Signup and view all the answers

What type of consulting services does the Institute for Safe Medication Practices offer?

Confidential consulting to evaluate medication systems Signup and view all the answers

Which of the following is a main focus of the Joint Commission Center for Transforming Healthcare?

Pursuing solutions for critical safety problems Signup and view all the answers

What resource does the National Association for Healthcare Quality provide to enhance professional knowledge?

Healthcare Quality Competency Framework Signup and view all the answers

How does the Joint Commission aim to improve patient safety standards?

Through literature and standards derived from various industries Signup and view all the answers

What aspect of patient safety does the National Patient Safety Foundation emphasize for healthcare leaders?

Strategic guidance for engaging leadership in change Signup and view all the answers

Which of the following tools is offered by the Joint Commission Center for Transforming Healthcare?

Oro 2.0 Resource Library Signup and view all the answers

What main component does the National Association for Healthcare Quality's framework emphasize?

Health data analytics and performance improvement Signup and view all the answers

What is a significant feature of the ISMP Medication Safety Alert! newsletters?

Updates on medication safety issues Signup and view all the answers

What is one of the three goals of the Patient-Centered Outcomes Research Institute (PCORI)?

Speed the implementation of patient-centered outcomes research Signup and view all the answers

Which of the following is a focus area of OSHA in healthcare facilities?

Understanding the unique challenges of hazardous workplaces Signup and view all the answers

What resource does the World Health Organization provide for healthcare professionals?

Patient Safety Curriculum Guide Signup and view all the answers

How does OSHA aim to improve safety culture in healthcare settings?

Through the implementation of safety and health management systems Signup and view all the answers

One of the research priorities of OSHA is to achieve which of the following?

Achieve health equity Signup and view all the answers

What is a key component of the safe patient handling resources provided by OSHA?

Programs that reduce workplace injuries Signup and view all the answers

What is one of the main focuses of the WHO's Patient Safety Curriculum Guide?

Learning from errors in healthcare Signup and view all the answers

OSHA provides training resources for which type of activities?

Hazardous activities Signup and view all the answers

What is a significant objective of the Patient-Centered Outcomes Research Institute?

Influence healthcare research to prioritize patient-centered outcomes Signup and view all the answers

What aspect of workplace safety does OSHA focus on preventing?

Workplace violence Signup and view all the answers

What is the estimated annual global cost associated with medication errors?

US$ 42 billion Signup and view all the answers

What percentage of surgical patients experience complications due to unsafe surgical care?

25% Signup and view all the answers

Approximately how many adults in outpatient settings experience a diagnostic error?

5% Signup and view all the answers

What is the estimated incidence of serious transfusion reactions per 100,000 blood components?

8.7 Signup and view all the answers

How many cases of venous thromboembolism occur annually in high-income nations?

3.9 million Signup and view all the answers

What is the burden of harm in Disability Adjusted Life Years (DALYs) caused by unsafe injections?

9.2 million Signup and view all the answers

What is the typical rate of healthcare-associated infections in high-income countries?

7 out of 100 Signup and view all the answers

Which of the following organizations proposed updates to hospital-acquired infections in 2008?

Centers for Medicare & Medicaid Services Signup and view all the answers

In which year did the Institute of Medicine's report 'To Err Is Human' prompt significant federal actions to reduce medical errors?

2000 Signup and view all the answers

How many serious reportable adverse events does the National Quality Forum describe as 'never events'?

12 Signup and view all the answers

What are the three broad aims of the National Strategy for Quality Improvement in Health Care?

Better care, healthier communities, and affordable care Signup and view all the answers

Which goal focuses on the experience of care for patients and their families?

Improve patient, family, and caregiver experience of care Signup and view all the answers

What significant act was passed in response to the 'To Err Is Human' report?

Patient Safety and Quality Improvement Act Signup and view all the answers

What was one of the major funding amounts awarded by CMS in 2016 to enhance patient safety?

$347 million Signup and view all the answers

Which organization provided input to develop the National Quality Strategy?

National Priorities Partnership Signup and view all the answers

Which of the following priorities aims to improve safety in healthcare delivery?

Reducing harm in delivery of care Signup and view all the answers

What is avoided by payers like CMS when serious reportable events occur in acute-care facilities?

Medicare payments Signup and view all the answers

What is emphasized in the CMS Quality Strategy concerning quality or value?

Alternative payment structures Signup and view all the answers

One of the goals of the National Strategy for Quality Improvement is to enable patients to navigate and manage care effectively. Which component supports this?

Accessing tools and support systems for care navigation Signup and view all the answers

What role does the National Academy of Medicine play in improving patient safety?

Reviewing strategies for patient safety improvement Signup and view all the answers

Which surgical event is categorized under the surgical or invasive procedure events?

Unintended retention of a foreign object Signup and view all the answers

What is a serious reportable environmental event regarding gas delivery in healthcare settings?

Misdelivery of oxygen or contaminated gas Signup and view all the answers

Which of the following incidents is classified as a patient protection event?

Patient elopement resulting in serious injury Signup and view all the answers

Which event from the care management category involves a recognizable medication error?

Patient death due to overdosing on a prescription Signup and view all the answers

In the domain of product or device events, what does intravascular air embolism indicate?

Patient harm during care involving IV sedation Signup and view all the answers

Which of the following events represents a potential criminal event in healthcare?

Sexual assault within a healthcare setting Signup and view all the answers

Which event is classified under radiologic events?

Serious injury linked to a metallic object in MRI Signup and view all the answers

What serious reportable event is tied to maternal care in low-risk pregnancies?

Maternal death associated with labor or delivery Signup and view all the answers

Which event indicates serious patient harm related to the administration of blood products?

Serious injury from unsafe blood product administration Signup and view all the answers

Among the environmental events, which situation presents a high risk during patient care?

Electric shock during treatment Signup and view all the answers

What primary function do patient safety organizations (PSOs) serve in the healthcare system?

Improving patient safety and analyzing patient safety work products. Signup and view all the answers

Which requirement must a patient safety organization (PSO) fulfill to be listed?

Submitting certifications to the Department of Health and Human Services. Signup and view all the answers

What essential aspect does the network of patient safety databases aim to improve?

The collection and management of patient safety data. Signup and view all the answers

Which organization is an example of a legislatively mandated entity focused on patient safety?

Oregon Patient Safety Commission Signup and view all the answers

What primary purpose does a Patient Safety Work Plan (PSWP) serve?

To foster a culture of safety and minimize patient risk Signup and view all the answers

Which of the following entities can qualify to become a Patient Safety Organization (PSO)?

For-profit and non-profit public and private entities Signup and view all the answers

What significant funding amount is allocated to the Partnership for Patients to improve healthcare quality, safety, and affordability?

$1 billion Signup and view all the answers

What is primarily included in the development and dissemination of information regarding Patient Safety and Quality Improvement?

Recommendations, protocols, and best practices Signup and view all the answers

Which of the following statements accurately describes the role of Patient Safety Organizations (PSOs)?

PSOs provide a secure environment for collecting and analyzing patient safety data Signup and view all the answers

Which statement best characterizes the role of national organizations in patient safety initiatives since 2000?

They implement safety practices and strategies across various organizations Signup and view all the answers

Which mechanism is designed to encourage a culture of patient safety within organizations?

Reporting mechanisms for adverse events Signup and view all the answers

What is a primary objective of the Partnership for Patients initiative?

Improving patient transition from acute care Signup and view all the answers

Which of the following aspects is included in the Quadruple Aim framework?

Improving the experience of providing care Signup and view all the answers

What role does the Josie King Foundation play in patient safety?

Uniting healthcare providers and consumers Signup and view all the answers

Which major funding source is mentioned as supporting the implementation of best practices in healthcare?

Centers for Medicare and Medicaid Services Signup and view all the answers

What is the vision of the Patient Safety Movement Foundation?

Eliminating all preventable medical errors by 2030 Signup and view all the answers

How does the Partnership for Patients initiative primarily collaborate with hospitals?

Through Hospital Improvement Innovation Networks Signup and view all the answers

What is a significant component of patient-centered care emphasized by the content?

Engagement of patients in their healthcare decisions Signup and view all the answers

What key focus area does the Quadruple Aim framework address in addition to patient care?

Workforce engagement and safety Signup and view all the answers

What was a major outcome of the Partnership for Patients since its initiation in 2015?

Collaborative work with over 3500 hospitals Signup and view all the answers

What approach is the ACA and its partnership focused on to minimize patient harm?

Utilizing evidence-based best practices Signup and view all the answers

Study Notes

Patient Safety Culture Composite Measures

Hospital surveys evaluate patient safety issues, medical errors, and event reporting
32 items measure 10 areas of patient safety culture
Data for 172 hospitals in 2021, representing 87,856 providers and staff
Progress in teamwork, management expectations, and organizational learning was noted, but continued improvement is needed in most hospitals.
Areas of strength include nonpunitive response to reporting, handoffs, transitions, and workload.
The survey results are used to establish a culture of safety in similar hospitals and hospital units.
Surveys cover hospital, medical office, nursing home, community, and ambulatory surgery center settings.
Providers rate safety culture in their unit and the whole organization annually.
Annual benchmarking data are available in AHRQ's comprehensive reports.
The surveys assess provider perceptions of patient safety culture at the unit and organizational levels.

Composite Measure Definitions

Communication about error: Staff are informed when errors occur, discuss ways to prevent errors, and are informed when changes are made.
Communication openness: Staff speak up when they see something unsafe and feel comfortable asking questions.
Handoffs and information exchange: Important patient care information is transferred across hospital units and during shift changes.
Hospital management support: Hospital management shows that patient safety is a top priority and provides adequate resources for patient safety.
Organizational learning - continuous improvement: Work processes are regularly reviewed, changes are made to keep mistakes from happening again, and changes are evaluated.
Reporting patient safety events: Mistakes of the following type are reported: (1) mistakes caught and corrected before reaching the patient, and (2) mistakes that could have harmed the patient but did not.
Response to error: Staff are treated fairly when they make mistakes and there is a focus on learning from mistakes and supporting staff involved in errors.
Staffing and work pace: There are enough staff to handle the workload, staff work appropriate hours and do not feel rushed, and there is appropriate reliance on temporary, float, or as-needed staff.
Supervisor, manager, or clinical leader support: Supervisors, managers, or clinical leaders consider staff suggestions for improving patient safety, do not encourage shortcuts, and take action to address patient safety concerns.
Teamwork: Staff work together as an effective team, helping each other during busy times, and are respectful.

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Description

This quiz examines the findings from hospital surveys assessing patient safety culture, based on data from 172 hospitals in 2021. It focuses on various measures such as communication about errors, management support, and areas of strength in patient safety practices. Test your knowledge on the key aspects of patient safety culture and the areas that need improvement.