Podcast
Questions and Answers
Accountability structures and systems do not include a patient safety officer.
Accountability structures and systems do not include a patient safety officer.
False
Awareness structures and systems involve direct patient input.
Awareness structures and systems involve direct patient input.
True
Leadership accountability is only directed towards senior management in accountability structures and systems.
Leadership accountability is only directed towards senior management in accountability structures and systems.
False
The safety program in healthcare operates independently of The Joint Commission's National Patient Safety Goals.
The safety program in healthcare operates independently of The Joint Commission's National Patient Safety Goals.
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Action structures and systems include regular actions of governance concerning culture measurement.
Action structures and systems include regular actions of governance concerning culture measurement.
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Safety budgets are part of the structures and systems-driving ability.
Safety budgets are part of the structures and systems-driving ability.
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Quantifiable impacts are not required when establishing a routine monitoring and evaluation plan.
Quantifiable impacts are not required when establishing a routine monitoring and evaluation plan.
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Culture management is included within the accountability structures and systems.
Culture management is included within the accountability structures and systems.
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The close call example resulted in the standardized color-coded wristband adoption in multiple states.
The close call example resulted in the standardized color-coded wristband adoption in multiple states.
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The only factor considered in evaluating the impact on patient safety is the number of incidents.
The only factor considered in evaluating the impact on patient safety is the number of incidents.
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Formal processes for disclosing unanticipated outcomes are unnecessary in healthcare settings.
Formal processes for disclosing unanticipated outcomes are unnecessary in healthcare settings.
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Timeliness in communication with patients should ideally occur within 48 hours after an adverse event.
Timeliness in communication with patients should ideally occur within 48 hours after an adverse event.
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Sentinel events are a type of serious unanticipated outcome that must be reported.
Sentinel events are a type of serious unanticipated outcome that must be reported.
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Emotional support is exclusively provided for patients involved in adverse events.
Emotional support is exclusively provided for patients involved in adverse events.
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Communication regarding unanticipated outcomes must include a promise of future prevention measures.
Communication regarding unanticipated outcomes must include a promise of future prevention measures.
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Home care settings are not included in the applicable clinical care settings for disclosure standards.
Home care settings are not included in the applicable clinical care settings for disclosure standards.
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Substantial additional care due to an unanticipated outcome does not need to be communicated to patients.
Substantial additional care due to an unanticipated outcome does not need to be communicated to patients.
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LIPs should be provided with a vague description of the organization's adverse event response program.
LIPs should be provided with a vague description of the organization's adverse event response program.
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Root Cause Analysis is a tool used for determining appropriate methods in patient safety.
Root Cause Analysis is a tool used for determining appropriate methods in patient safety.
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Enterprise Risk Management primarily focuses on only financial risks within healthcare organizations.
Enterprise Risk Management primarily focuses on only financial risks within healthcare organizations.
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An effective patient safety system includes monitoring progress and understanding the epidemiology of risks.
An effective patient safety system includes monitoring progress and understanding the epidemiology of risks.
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Implementing a punitive policy for reporting medical errors encourages staff to report incidents.
Implementing a punitive policy for reporting medical errors encourages staff to report incidents.
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FMEA stands for Faulty Mode and Effects Analysis.
FMEA stands for Faulty Mode and Effects Analysis.
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Patient safety indicators are monitored without relation to the 'Scope of Service'.
Patient safety indicators are monitored without relation to the 'Scope of Service'.
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Creating a patient safety-conscious environment is a key component of performance improvement in healthcare.
Creating a patient safety-conscious environment is a key component of performance improvement in healthcare.
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Strategic risks in healthcare are primarily concerned with clinical outcomes.
Strategic risks in healthcare are primarily concerned with clinical outcomes.
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Integrating patient safety plans into performance improvement programs is unnecessary for effective healthcare delivery.
Integrating patient safety plans into performance improvement programs is unnecessary for effective healthcare delivery.
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Proactive risk assessment is achieved exclusively through retrospective analysis of past incidents.
Proactive risk assessment is achieved exclusively through retrospective analysis of past incidents.
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The primary goal of risk management in the present is to improve patient safety and minimize the risk of harm through understanding systemic factors.
The primary goal of risk management in the present is to improve patient safety and minimize the risk of harm through understanding systemic factors.
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In the past, the only method required for reporting occurrences was an electronic form.
In the past, the only method required for reporting occurrences was an electronic form.
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Current practices in risk management encourage the investigation of any incident, regardless of its severity.
Current practices in risk management encourage the investigation of any incident, regardless of its severity.
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Today, information from risk investigations is solely kept confidential without sharing corrective actions.
Today, information from risk investigations is solely kept confidential without sharing corrective actions.
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In the past, when adverse incidents occurred, the approach was to conduct interviews with all staff members involved together.
In the past, when adverse incidents occurred, the approach was to conduct interviews with all staff members involved together.
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The guiding principle of Governance & Culture in ERM emphasizes attracting and retaining capable individuals.
The guiding principle of Governance & Culture in ERM emphasizes attracting and retaining capable individuals.
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Risks associated with technology only involve equipment and devices, excluding methods and systems.
Risks associated with technology only involve equipment and devices, excluding methods and systems.
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The present approach to addressing patient communication about adverse outcomes is to provide vague information only when necessary.
The present approach to addressing patient communication about adverse outcomes is to provide vague information only when necessary.
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Monitoring the effectiveness of patient safety improvements is considered a necessary step in today's risk management.
Monitoring the effectiveness of patient safety improvements is considered a necessary step in today's risk management.
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Hazard risks in healthcare are primarily associated with financial implications of business interruptions.
Hazard risks in healthcare are primarily associated with financial implications of business interruptions.
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The primary goal of the Enterprise Risk Management (ERM) program is to enhance financial protection by preventing losses from various risks.
The primary goal of the Enterprise Risk Management (ERM) program is to enhance financial protection by preventing losses from various risks.
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Effective strategies for proactive error reduction and patient safety discourage staff from reporting errors to avoid blame.
Effective strategies for proactive error reduction and patient safety discourage staff from reporting errors to avoid blame.
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The risk manager's responsibilities include regulatory compliance and collaboration with safety officers.
The risk manager's responsibilities include regulatory compliance and collaboration with safety officers.
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A formal ERM plan should explicitly exclude data collection and reporting mechanisms.
A formal ERM plan should explicitly exclude data collection and reporting mechanisms.
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Periodic evaluation and feedback are essential to monitor the progress of strategies within the ERM program.
Periodic evaluation and feedback are essential to monitor the progress of strategies within the ERM program.
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Identifying, evaluating, and prioritizing risks is not a key function of ERM in healthcare.
Identifying, evaluating, and prioritizing risks is not a key function of ERM in healthcare.
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Patient safety indicators are analyzed solely for financial performance without considering clinical implications.
Patient safety indicators are analyzed solely for financial performance without considering clinical implications.
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The risk manager should possess knowledge of healthcare law and the legal system to perform their duties effectively.
The risk manager should possess knowledge of healthcare law and the legal system to perform their duties effectively.
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One of the possible causes of losses for organizations is patient harm from unqualified clinical staff.
One of the possible causes of losses for organizations is patient harm from unqualified clinical staff.
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Enterprise Risk Management (ERM) primarily deals with procedural risks in clinical environments.
Enterprise Risk Management (ERM) primarily deals with procedural risks in clinical environments.
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Vicarious liability holds an organization responsible for all actions of independent contractors they employ.
Vicarious liability holds an organization responsible for all actions of independent contractors they employ.
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Only 10% of healthcare errors result in patient harm.
Only 10% of healthcare errors result in patient harm.
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A structured mechanism for reviewing reports is not necessary for effective risk management.
A structured mechanism for reviewing reports is not necessary for effective risk management.
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The root causes of risks can be identified through retrospective and prospective approaches.
The root causes of risks can be identified through retrospective and prospective approaches.
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In organizations with punitive cultures, staff are more likely to report near misses and errors.
In organizations with punitive cultures, staff are more likely to report near misses and errors.
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Ostensible agency requires a patient to demonstrate clear and obvious negligence to establish their case.
Ostensible agency requires a patient to demonstrate clear and obvious negligence to establish their case.
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Less than 50% of healthcare staff feel that their event reports lead to personal repercussions.
Less than 50% of healthcare staff feel that their event reports lead to personal repercussions.
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The failure mode and effects analysis (FMEA) is primarily focused on financial risks only.
The failure mode and effects analysis (FMEA) is primarily focused on financial risks only.
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Incidents of patient harm are primarily reported by nurses and physicians due to their visibility of care processes.
Incidents of patient harm are primarily reported by nurses and physicians due to their visibility of care processes.
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Incident reporting systems fail to capture a significant majority of events due to staff reluctance.
Incident reporting systems fail to capture a significant majority of events due to staff reluctance.
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The percentage of hospitals indicating adequate staffing increased from 56% in 2019 to 68% in 2021.
The percentage of hospitals indicating adequate staffing increased from 56% in 2019 to 68% in 2021.
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The measure for falls in the NQF Patient Safety Portfolio includes a focus on patient burn rates.
The measure for falls in the NQF Patient Safety Portfolio includes a focus on patient burn rates.
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The area of 'Handoffs and Transitions' showed an increase from 58% to 64% between 2019 and 2021.
The area of 'Handoffs and Transitions' showed an increase from 58% to 64% between 2019 and 2021.
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All measures in the NQF Patient Safety Portfolio are exclusively focused on surgical patient safety.
All measures in the NQF Patient Safety Portfolio are exclusively focused on surgical patient safety.
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The improvement in 'Staffing and Work Pace' signifies that more hospital staff feel rushed in their duties.
The improvement in 'Staffing and Work Pace' signifies that more hospital staff feel rushed in their duties.
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Hospitals' ability to communicate important patient care information during shift changes remained unchanged from 2019 to 2021.
Hospitals' ability to communicate important patient care information during shift changes remained unchanged from 2019 to 2021.
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The Patient Fall Rate measure is included in the list of fall-related measures in the NQF Patient Safety Portfolio.
The Patient Fall Rate measure is included in the list of fall-related measures in the NQF Patient Safety Portfolio.
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The data from the SOPS Hospital Survey 2.0 has been published only once, with no subsequent reports available.
The data from the SOPS Hospital Survey 2.0 has been published only once, with no subsequent reports available.
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The National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-Onset Clostridium Difficile Infection Measure is identified by the code (1717).
The National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-Onset Clostridium Difficile Infection Measure is identified by the code (1717).
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Percentage of residents with pressure ulcers that are new or worsened is represented by the code (0679).
Percentage of residents with pressure ulcers that are new or worsened is represented by the code (0679).
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Medication reconciliation is a measure related to medication safety and is identified by the code (0541).
Medication reconciliation is a measure related to medication safety and is identified by the code (0541).
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The Failure to Rescue In-Hospital Mortality measure is risk adjusted and has the code (0352).
The Failure to Rescue In-Hospital Mortality measure is risk adjusted and has the code (0352).
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The measure for Venous Thromboembolism patients with anticoagulation overlap therapy is identified by the code (0371).
The measure for Venous Thromboembolism patients with anticoagulation overlap therapy is identified by the code (0371).
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The measure for the documentation of current medications in the medical record is represented by the code (0419).
The measure for the documentation of current medications in the medical record is represented by the code (0419).
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Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis is assigned the code (0239) in the safety measures.
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis is assigned the code (0239) in the safety measures.
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Antipsychotic Use in Children Under 5 Years Old is monitored with the code (2337).
Antipsychotic Use in Children Under 5 Years Old is monitored with the code (2337).
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The measure for the Pressure Ulcer Prevention and Care has the code (0337).
The measure for the Pressure Ulcer Prevention and Care has the code (0337).
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Skill Mix in workforce safety includes Registered Nurse (RN), Licensed Vocational/Practical Nurse (LVN/LPN), and Unlicensed Assistive Personnel (UAP) under the code (0204).
Skill Mix in workforce safety includes Registered Nurse (RN), Licensed Vocational/Practical Nurse (LVN/LPN), and Unlicensed Assistive Personnel (UAP) under the code (0204).
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Which of the following best describes the focus of proactive risk management in healthcare?
Which of the following best describes the focus of proactive risk management in healthcare?
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In the context of Failure Mode and Effects Analysis (FMEA), what is primarily assessed?
In the context of Failure Mode and Effects Analysis (FMEA), what is primarily assessed?
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Which risk factor is NOT typically included in proactive risk assessment methods?
Which risk factor is NOT typically included in proactive risk assessment methods?
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What is the main goal of conducting a Root Cause Analysis (RCA) in healthcare settings?
What is the main goal of conducting a Root Cause Analysis (RCA) in healthcare settings?
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Which type of risk assessment primarily aims at minimizing damage once incidents have already occurred?
Which type of risk assessment primarily aims at minimizing damage once incidents have already occurred?
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Which of the following is a common method for managing patient safety risk in healthcare organizations?
Which of the following is a common method for managing patient safety risk in healthcare organizations?
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What is a key component of effective tools and strategies for patient safety programs?
What is a key component of effective tools and strategies for patient safety programs?
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What is often a result of effective risk control in healthcare settings?
What is often a result of effective risk control in healthcare settings?
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What is the purpose of conducting an event tree analysis of mental health in emergency departments?
What is the purpose of conducting an event tree analysis of mental health in emergency departments?
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What was the outcome of the hazard identification assessment for patient-owned equipment?
What was the outcome of the hazard identification assessment for patient-owned equipment?
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In the FMEA process for interhospital patient transfers, what is one of the key steps taken?
In the FMEA process for interhospital patient transfers, what is one of the key steps taken?
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During the set-up stage of a proactive risk assessment, which step involves defining the assessment's boundaries?
During the set-up stage of a proactive risk assessment, which step involves defining the assessment's boundaries?
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What methodology might be determined during the 'Do' phase of a proactive risk assessment?
What methodology might be determined during the 'Do' phase of a proactive risk assessment?
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Which of the following is a critical component of the results phase in proactive risk assessments?
Which of the following is a critical component of the results phase in proactive risk assessments?
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What should be prepared before initiating a proactive risk assessment according to the established workflow?
What should be prepared before initiating a proactive risk assessment according to the established workflow?
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Which aspect is NOT involved in identifying during the 'Do' phase of proactive risk assessment?
Which aspect is NOT involved in identifying during the 'Do' phase of proactive risk assessment?
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Which step is NOT included in the Setup stage of proactive risk assessment?
Which step is NOT included in the Setup stage of proactive risk assessment?
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What is one of the primary purposes of implementing Red Rules in a healthcare setting?
What is one of the primary purposes of implementing Red Rules in a healthcare setting?
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Which aspect is NOT considered in Root Cause Analysis (RCA)?
Which aspect is NOT considered in Root Cause Analysis (RCA)?
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During the 'Do' stage of proactive risk assessment, which of the following is NOT one of the activities performed?
During the 'Do' stage of proactive risk assessment, which of the following is NOT one of the activities performed?
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In the context of proactive risk assessment, FMEA is primarily used to...
In the context of proactive risk assessment, FMEA is primarily used to...
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Which of these is a recommended method to establish a successful Root Cause Analysis?
Which of these is a recommended method to establish a successful Root Cause Analysis?
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What defines a key characteristic of Red Rules in a healthcare environment?
What defines a key characteristic of Red Rules in a healthcare environment?
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In the Results stage of proactive risk assessment, which step is NOT part of the evaluation process?
In the Results stage of proactive risk assessment, which step is NOT part of the evaluation process?
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Which of the following is essential for practicing proactive risk assessment effectively?
Which of the following is essential for practicing proactive risk assessment effectively?
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Which proactive risk assessment opportunity involves assessing patient-owned equipment?
Which proactive risk assessment opportunity involves assessing patient-owned equipment?
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What is one outcome that resulted from event tree analysis of mental health patients in the emergency department?
What is one outcome that resulted from event tree analysis of mental health patients in the emergency department?
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What is the primary purpose of conducting a failure modes and effects analysis (FMEA) during interhospital patient transfers?
What is the primary purpose of conducting a failure modes and effects analysis (FMEA) during interhospital patient transfers?
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What is the first step in the proactive risk assessment workflow?
What is the first step in the proactive risk assessment workflow?
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How can hospitals determine the severity of identified failure modes in a proactive risk assessment?
How can hospitals determine the severity of identified failure modes in a proactive risk assessment?
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What was a significant action taken after the hazard identification of patient-owned equipment?
What was a significant action taken after the hazard identification of patient-owned equipment?
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What aspect does the 'Do' phase in proactive risk assessment primarily focus on?
What aspect does the 'Do' phase in proactive risk assessment primarily focus on?
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Which element is NOT part of the proactive risk assessment framework?
Which element is NOT part of the proactive risk assessment framework?
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What role does process mapping play in an FMEA of interhospital patient transfers?
What role does process mapping play in an FMEA of interhospital patient transfers?
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Study Notes
Patient Safety Elements
- Awareness structures and systems provide continuous information about potential risks, hazards, and performance gaps.
- These structures include risk identification, culture management, feedback intervention, direct patient input, and governance board/senior management briefings.
- Structures and systems-driving ability enables leaders to assess capacity, resources, and competence, all necessary for implementing patient safety changes.
- This includes patient safety budgets, people systems, quality systems, and technical systems.
- Accountability structures ensure direct accountability to governing bodies, senior management, mid-level staff, physician leaders, and frontline staff, emphasizing a patient safety program.
- Included in accountability structures are a patient safety officer, organization-wide leadership accountability, interdisciplinary patient safety committees, and external reporting.
- Action structures empower leaders to take direct action, including quality/performance improvement programs, regular governance actions, senior administrative leadership actions, unit/service line actions, with regular teamwork actions ensuring safety.
Safety Program
- Healthcare professionals collaborate to improve compliance with National Patient Safety Goals, Leapfrog safe practices, and NQF-endorsed measures.
- Standards and resources improve patient identification accuracy, ensure effective caregiver communication, and implement high-alert medication and surgery safeguards.
- Proposed solutions to improve patient safety include electronic health information accessibility and collaborative decision-making with patients.
- A nurse placed a yellow wristband signifying a restricted extremity, but this was an error. This highlights the importance of careful application of standardized procedures, standardized procedures, and clear communication.
- Standardized color-coded wristbands are now used in Pennsylvania and 41 other states/U.S. military, promoting standardization and reducing errors.
- This highlights the need for improvement in communication and implementation of patient safety procedures.
- Healthcare organizations should routinely invite providers and consumers to collaboratively make decisions regarding patient care.
- The yellow wristband example highlights a critical issue in patient safety, the importance of verification prior to initiating procedures.
- Establishing plans for evaluating the impact of safety initiatives on health outcomes, quality of care, and patient safety are important to support decision-making.
- A key component is the proactive identification of risks and their subsequent mitigation.
- Systems should be in place to facilitate disclosure and rapid response regarding serious events.
Safety Issues and Actions
- A yellow wristband, signifying a restricted extremity, was incorrectly applied to a patient, highlighting the need for careful application of standardized procedures, standardized procedures, and clear communication.
- A near miss program encouraged reporting of patient risk situations.
- Pennsylvania and 41 other states/U.S. military adopted standardized color-coded wristbands, improving standardization and reducing errors.
- Identifying and addressing seemingly small interventions can lead to big, sustainable changes in healthcare.
- Evaluation plans should assess impact on patient safety, healthcare quality, and health outcomes, including collaboration by providers and consumers, for patient care improvements.
- Feasability, usability of potential interventions, with clearly defined targets for intervention, and quantifiable measures of success are important to evaluate the impact on patient safety.
- Quantifying the effort impact (e.g., number of incidents, occurrence rates) and affected parties (e.g., patients, clinicians, departments) is crucial for improvement.
- Incorrect placement of a yellow wristband (restricted extremity) on a patient during blood draw highlights the need for standardization, careful application of procedures, thorough verification before procedure, and appropriate communication reducing potential harm.
- Organizations should develop and implement systems to capture near-miss events and analyse their causes, in addition to serious events, ensuring a comprehensive understanding of potential risks.
- The importance of proactive identification of risks and their subsequent mitigation is crucial.
- Systems should be in place to facilitate disclosure and rapid response regarding serious events.
- Organizations should have readily available resources to support providers and consumers to make collaborative decisions regarding patient care.
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Description
This quiz explores the essential elements of patient safety management. It covers awareness structures, accountability, and action systems that empower leaders in healthcare settings. Participants will understand how these systems contribute to identifying risks and ensuring continuous improvement in patient care.
