Patient Safety 3
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Questions and Answers

What was the primary outcome of the event tree analysis focused on mental health in ED patients?

  • Improved monitoring of patient-owned equipment
  • Training for staff in crisis prevention (correct)
  • Development of a new mental health treatment protocol
  • Increased hospital capacity for mental health issues

    • What was the reason for the hazard identification assessment conducted regarding patient-owned equipment?

  • To enhance staff training on equipment use
  • To recommend patient ownership of hospital equipment
  • To address a post-surgery incident involving this equipment (correct)
  • To improve overall hospital equipment

    • Which of the following actions is NOT part of the 'Do' stage in the proactive risk assessment workflow?

  • Selecting participants for the assessment
  • Identifying failure modes and impacts
  • Setting the safety objective to study (correct)
  • Conducting simulations for potential failures

    • During which phase of a proactive risk assessment is the scoring system specified?

    <p>Results</p> Signup and view all the answers

    What main benefit does process mapping provide in the FMEA of interhospital patient transfers?

    <p>Assists in designing a form that improves patient safety</p> Signup and view all the answers

    Why is it important to select a wide team for the proactive risk assessment?

    <p>To ensure diverse perspectives on patient safety</p> Signup and view all the answers

    What aspect of the proactive risk assessment does the phrase 'real work' refer to?

    <p>Actual practices and processes involved</p> Signup and view all the answers

    What is a primary goal of proactive risk assessments in healthcare settings?

    <p>To identify and manage potential risks before they result in harm</p> Signup and view all the answers

    What is the primary purpose of Root Cause Analysis (RCA)?

    <p>To determine the root cause of process variations after an event.</p> Signup and view all the answers

    Which organization developed an RCA toolkit for investigating adverse incidents in healthcare?

    <p>Oregon Patient Safety Commission</p> Signup and view all the answers

    How do Red Rules contribute to safety in healthcare?

    <p>By allowing any worker to stop a process when a safety violation is observed.</p> Signup and view all the answers

    What is a key characteristic of Red Rules compared to traditional safety measures?

    <p>They emphasize commitment rather than punishment.</p> Signup and view all the answers

    Which of the following is NOT a factor examined in Root Cause Analysis?

    <p>Patient satisfaction rates</p> Signup and view all the answers

    What technique is commonly used in RCA to explore root causes?

    <p>The 5 Whys method</p> Signup and view all the answers

    What should be ensured for Red Rules to be effective according to the ISMP?

    <p>They must be possible and desirable for all individuals involved.</p> Signup and view all the answers

    What role do managers play in the implementation of Red Rules?

    <p>They support employees in addressing safety issues.</p> Signup and view all the answers

    What is the primary responsibility of the RCA² team during the first 72 hours of the process?

    <p>Conduct interviews and site visits</p> Signup and view all the answers

    What occurs during the 30-45 day phase of the RCA² process?

    <p>Measurement of compliance levels</p> Signup and view all the answers

    What is essential for ensuring consistency in the RCA² process?

    <p>Having a core group participate in all phases</p> Signup and view all the answers

    Which of the following steps is NOT included in the RCA² process?

    <p>Conducting external audits</p> Signup and view all the answers

    Who is responsible for providing feedback at the end of the RCA² process?

    <p>A responsible individual with authority</p> Signup and view all the answers

    In which phase of the RCA² process are causal statements developed?

    <p>Development phase</p> Signup and view all the answers

    What immediate actions are taken when an event occurs according to the RCA² process?

    <p>Secure the situation and address patient safety</p> Signup and view all the answers

    What is included in the 'Measurement' step of the RCA² process?

    <p>Determining compliance levels and measurement dates</p> Signup and view all the answers

    What is a significant concern regarding the deployment of Red Rules in healthcare settings?

    <p>They may be perceived as blaming and punitive.</p> Signup and view all the answers

    How do checklists contribute to patient safety in complex healthcare environments?

    <p>They allow users to pause and review actions before proceeding.</p> Signup and view all the answers

    Which of the following is a characteristic of a just checklist for antibiotic stewardship?

    <p>It assesses the core elements of antibiotic prescribing regularly.</p> Signup and view all the answers

    What role do checklists play in the context of surgical procedures?

    <p>They help minimize the likelihood of errors and enhance safety.</p> Signup and view all the answers

    In what way have studies shown the effectiveness of Red Rules?

    <p>They have no discernible impact on reported safety measures.</p> Signup and view all the answers

    Which factor is essential for the successful use of checklists in healthcare settings?

    <p>The user must be able to understand and follow them easily.</p> Signup and view all the answers

    What is a vital component of a successful checklist for reducing catheter-related bloodstream infections?

    <p>Full-barrier precautions during the insertion process.</p> Signup and view all the answers

    What aspect of human factors engineering underpins the development of safety checklists?

    <p>Improved communication and user experience.</p> Signup and view all the answers

    Which of the following is NOT a type of risk that checklists help manage in healthcare settings?

    <p>Staffing shortages.</p> Signup and view all the answers

    What is a potential risk identified in healthcare settings that checklists aim to address?

    <p>Adverse events from complex pathways of care.</p> Signup and view all the answers

    What is required of a facility when using safety-engineered needles and sharps?

    <p>To document the use of safety-engineered sharps annually</p> Signup and view all the answers

    Which of the following protective measures is not specifically mandated for exposure to bloodborne pathogens?

    <p>Having a designated smoking area</p> Signup and view all the answers

    What must employees do immediately after skin exposure to blood or OPIM?

    <p>Wash the exposed skin</p> Signup and view all the answers

    Eyewash stations should be located how far from areas where exposure is likely to occur?

    <p>Within 10 seconds</p> Signup and view all the answers

    Which activity is expressly prohibited in work areas at risk of occupational exposure?

    <p>Eating</p> Signup and view all the answers

    What should be the bleach solution ratio for surface disinfecting if bleach is used?

    <p>1:10</p> Signup and view all the answers

    What is the primary focus of maintaining a sufficient PPE supply?

    <p>To prevent potential exposure</p> Signup and view all the answers

    What must be documented regarding sharps containers in a facility?

    <p>Routine inspections to prevent overfilling</p> Signup and view all the answers

    Hepatitis B vaccinations should be offered to which group of employees?

    <p>Employees exposed to blood or OPIM</p> Signup and view all the answers

    How should food and drinks be stored in a facility with blood or OPIM exposure risks?

    <p>In designated storage areas away from exposure</p> Signup and view all the answers

    Which of the following elements is NOT a responsibility of the Infection Prevention and Control program?

    <p>Identification of useful medical devices</p> Signup and view all the answers

    What is the primary goal of an Infection Prevention and Control (IPC) program?

    <p>To minimize the risks of infections among various groups</p> Signup and view all the answers

    Which risk assessment factor is NOT mentioned as being considered for an IPC program?

    <p>Current staffing levels</p> Signup and view all the answers

    In what way do health quality professionals support the use of checklists?

    <p>By elucidating their benefits within management systems</p> Signup and view all the answers

    Which of the following is a primary method used in the prevention and control of infections?

    <p>Surveillance and epidemiological tracking</p> Signup and view all the answers

    What is a significant benefit of using safety checklists in healthcare settings?

    <p>Ensuring correct and consistent procedures</p> Signup and view all the answers

    Which of the following components is essential for effective IPC strategies?

    <p>High-level disinfection protocols</p> Signup and view all the answers

    What aspect of checklists contributes significantly to risk reduction in healthcare?

    <p>Regimentation of practices</p> Signup and view all the answers

    What is a vital part of the IPC program that helps ensure quality control?

    <p>Data collection methods</p> Signup and view all the answers

    Which practice is NOT included in the prevention and control methods for infections?

    <p>Policies to permit unrestricted patient visits</p> Signup and view all the answers

    Which of the following statements best represents the concept of Collective Mindfulness in health IT?

    <p>Detecting and mitigating health IT-related errors through shared awareness.</p> Signup and view all the answers

    What is one potential consequence of alarm fatigue in healthcare settings?

    <p>Misdirection of attention to critical alarm signals.</p> Signup and view all the answers

    What factor must health IT systems align with to operate effectively within healthcare delivery?

    <p>Patient and clinical workflow expectations.</p> Signup and view all the answers

    Which of the following components is NOT typically included in Electronic Health Records (EHRs)?

    <p>Patient billing information.</p> Signup and view all the answers

    In analyzing adverse events in healthcare, what is the goal of Comprehensive Analysis?

    <p>To systematically evaluate whether health IT contributed to harm.</p> Signup and view all the answers

    What is a primary challenge associated with the implementation of health IT systems?

    <p>Ineffective training programs for healthcare staff.</p> Signup and view all the answers

    Which of the following is a potential issue stemming from poor interoperability in health IT systems?

    <p>Incorrect patient matching in health information exchanges.</p> Signup and view all the answers

    What role do leadership practices play in the context of health IT adoption?

    <p>Mitigating risks associated with technology implementation.</p> Signup and view all the answers

    What is an emergent property of the healthcare system that affects safety as identified in health IT discussions?

    <p>The external environment and regulatory landscape.</p> Signup and view all the answers

    Which dimension is NOT included in the Health Information Technology Safety Measurement Framework (HITS Framework)?

    <p>Patient satisfaction surveys</p> Signup and view all the answers

    What can result from flawed matching algorithms in Health Information Exchange (HIE)?

    <p>Propagation of data quality issues</p> Signup and view all the answers

    Which of the following is NOT a key component of the technology strategy for Health Information Technology?

    <p>Supporting private health information management</p> Signup and view all the answers

    What aspect of AI and machine learning in healthcare primarily involves predictive modeling?

    <p>Mining vast amounts of data for pattern recognition</p> Signup and view all the answers

    What is one expected impact of integrating Health IT safety with patient safety programs?

    <p>Enhancing organizational learning</p> Signup and view all the answers

    Which of the following characteristics is essential for eMeasures in health IT safety measurement?

    <p>Feasibility and usability</p> Signup and view all the answers

    Which factor could lead to critical delays in accessing data during Health Information Exchange?

    <p>Loss of data integrity during transmission</p> Signup and view all the answers

    What is the primary goal of the Nationwide Health Information Network (NHIN)?

    <p>To ensure secure consumer health information exchange</p> Signup and view all the answers

    Which outcome is NOT expected from the refinement of measurement tools in Health IT safety?

    <p>Acquisition of advanced analytical software</p> Signup and view all the answers

    What type of errors can propagate through Health Information Exchanges (HIE)?

    <p>Entry errors and incomplete data</p> Signup and view all the answers

    What is a potential downside of using computerized provider order entry systems in healthcare?

    <p>New opportunities for errors</p> Signup and view all the answers

    Which benefit is associated with clinical decision support systems?

    <p>Improved monitoring of patient conditions</p> Signup and view all the answers

    Which of the following is a safety concern regarding bar coding in healthcare?

    <p>Introduction of workarounds</p> Signup and view all the answers

    What is a notable safety concern related to patient engagement tools?

    <p>Potential reliability issues of entered data</p> Signup and view all the answers

    What is a common misconception about computerized provider order entry systems?

    <p>They only improve order legibility</p> Signup and view all the answers

    Which problem may arise from the high override rate of alerts in clinical decision support systems?

    <p>Decreased efficiency in patient care</p> Signup and view all the answers

    Which factor contributes to the increased risk of medication errors when using computerized order entry?

    <p>Fragmented displays of patient medications</p> Signup and view all the answers

    What misconception might healthcare professionals have about bar coding's influence on medication errors?

    <p>It completely eliminates all forms of medication errors</p> Signup and view all the answers

    What is a consequence of increased ordering time in computerized provider order entry systems?

    <p>Potential disruption in workflow</p> Signup and view all the answers

    Which issue is not commonly associated with clinical decision support systems?

    <p>Reduced management errors in critical situations</p> Signup and view all the answers

    What is one of the potential benefits of incorporating AI in healthcare?

    <p>Facilitate the diagnosis and treatment of rare diseases</p> Signup and view all the answers

    Which of the following is a safety concern associated with the implementation of AI in clinical settings?

    <p>Overreliance on technology diminishing human expertise</p> Signup and view all the answers

    What is a primary responsibility of healthcare quality professionals regarding health IT?

    <p>Mitigating risks and reducing preventable harm</p> Signup and view all the answers

    What has been a significant evolution in public reporting within the healthcare sector?

    <p>Shifting from voluntary to mandatory and improvement-focused reporting</p> Signup and view all the answers

    Which toolkits does the partnership for Health IT Patient Safety currently offer?

    <p>Patient identification and cut and paste</p> Signup and view all the answers

    What is a key aspect of the Chesapeake Regional Information System for Our Patients?

    <p>Facilitating secure data sharing among various healthcare entities</p> Signup and view all the answers

    Which statement is true regarding telehealth and healthcare accessibility?

    <p>Telehealth helps remove barriers to accessing healthcare services.</p> Signup and view all the answers

    What is a crucial factor for the effective use of health IT in improving patient safety?

    <p>Sufficient training and support for healthcare providers</p> Signup and view all the answers

    What trend in healthcare is indicated by emphasizing consumer capabilities in managing health information?

    <p>Increased consumer autonomy in health management</p> Signup and view all the answers

    What is a limitation identified regarding the current AI applications in healthcare?

    <p>There is a lack of extensive effectiveness research on algorithms</p> Signup and view all the answers

    Using non-standard identifiers in electronic fields helps prevent duplicate records.

    <p>False</p> Signup and view all the answers

    Integrating new technologies is unnecessary for improving patient identification processes.

    <p>False</p> Signup and view all the answers

    Consistent display of patient attributes across health IT systems makes identification more challenging.

    <p>False</p> Signup and view all the answers

    Monitoring systems should only be implemented reactively to detect patient identification errors.

    <p>False</p> Signup and view all the answers

    High-specificity active alerts are designed to reduce errors in patient identification.

    <p>True</p> Signup and view all the answers

    Using a multi-step process for confirming patient identity increases the likelihood of errors.

    <p>False</p> Signup and view all the answers

    It's important to maintain a low level of detail in patient identifiers for better matching.

    <p>False</p> Signup and view all the answers

    Distinguishing information on screens and printouts aids in improving patient identification.

    <p>True</p> Signup and view all the answers

    The Center for Food Safety and Applied Nutrition (CFSAN) Adverse Event Reporting System (CAERS) primarily collects information about adverse events related to pharmaceuticals.

    <p>False</p> Signup and view all the answers

    The Vaccine Adverse Event Reporting System (VAERS) is managed solely by the CDC.

    <p>False</p> Signup and view all the answers

    The National Healthcare Safety Network (NHSN) has contributed to the goal of achieving zero healthcare-associated infections (HAIs).

    <p>True</p> Signup and view all the answers

    Twenty-seven states, including the District of Columbia, have enacted legislation to support reporting of adverse events to federal agencies.

    <p>False</p> Signup and view all the answers

    CMS initiated the Hospital Compare rating system in 2010 to enhance hospital performance transparency.

    <p>False</p> Signup and view all the answers

    Mandatory reporting systems for adverse events were recommended by the Institute of Medicine (IOM) in 1999, starting with hospitals and expanding later to other care settings.

    <p>True</p> Signup and view all the answers

    The effectiveness of reporting systems in patient safety is completely understood and documented.

    <p>False</p> Signup and view all the answers

    Nine states have reported a decrease in provider transparency and awareness of patient safety due to their reporting systems.

    <p>False</p> Signup and view all the answers

    Public reporting of infection rates is deemed a 'new clinical mandate' for infection prevention and control.

    <p>True</p> Signup and view all the answers

    The Centers for Medicare & Medicaid Services (CMS) has reduced Medicare payments based on hospitals' rankings in the best quartile for hospital-acquired conditions.

    <p>False</p> Signup and view all the answers

    What was a significant outcome of the Hospital Quality Alliance's collaboration with CMS?

    <p>Public reporting efforts beyond structural quality measures</p> Signup and view all the answers

    Which of the following tools is primarily used by NCQA to assess the performance of health plans?

    <p>Healthcare Effectiveness Data and Information Set (HEDIS)</p> Signup and view all the answers

    What is the primary purpose of continuous measurement and monitoring in healthcare?

    <p>To provide insights into the impacts of interventions on patient safety</p> Signup and view all the answers

    How does The Joint Commission (TJC) use data in their accreditation standards?

    <p>To inform treatment protocols and safety measures</p> Signup and view all the answers

    What aspect of health plan accountability is addressed by HEDIS metrics?

    <p>Key dimensions of care and service provided to patients</p> Signup and view all the answers

    What ongoing support does The Joint Commission provide through ORYX®?

    <p>Standardized monitoring for care, treatment, and service goals</p> Signup and view all the answers

    Which area is NOT specifically addressed in HEDIS as a patient safety concern?

    <p>Safe antipsychotic drug use in adults</p> Signup and view all the answers

    What is a focus of the consolidated programs developed by CMS in 2020?

    <p>Streamlined reporting for value-based purchasing and provider selection</p> Signup and view all the answers

    What is the primary objective of the Leapfrog Group?

    <p>To guide healthcare in enhancing patient safety</p> Signup and view all the answers

    In the context of medication safety, what is the purpose of medication reconciliation?

    <p>To avoid inconsistencies in medication information</p> Signup and view all the answers

    Which example is associated with the Universal Protocol for preventing surgical errors?

    <p>Performing a time-out before procedures</p> Signup and view all the answers

    What strategy is emphasized under Goal 15 related to identifying safety risks in patients?

    <p>Zero suicide approach for risk identification</p> Signup and view all the answers

    What is a critical component of achieving Goal 2 regarding communication among caregivers?

    <p>Timely reporting of critical test results</p> Signup and view all the answers

    Which guideline should be followed to reduce the risk of healthcare-associated infections?

    <p>Compliance with hand hygiene guidelines</p> Signup and view all the answers

    What is a necessary action prior to performing surgical procedures according to the Universal Protocol?

    <p>Performing a time-out for confirmation</p> Signup and view all the answers

    Which practice is particularly emphasized to help prevent wrong-site surgeries?

    <p>Enforcing strict pre-procedure verification processes</p> Signup and view all the answers

    What aspect is NOT typically measured by safety culture measures in healthcare organizations?

    <p>Error rates</p> Signup and view all the answers

    Which of the following is a required characteristic of the survey tool used to evaluate the culture of safety in hospitals?

    <p>It needs to be reliable and supported by peer-reviewed literature</p> Signup and view all the answers

    What is the primary purpose of the SBAR communication tool in healthcare?

    <p>To facilitate effective communication of a patient's condition</p> Signup and view all the answers

    What is NOT one of the roles of the National Quality Forum (NQF) in patient safety?

    <p>Conducting clinical trials for new medications</p> Signup and view all the answers

    Which process is primarily used by healthcare organizations to evaluate their safety culture?

    <p>Surveys</p> Signup and view all the answers

    What key characteristic is essential for the effectiveness of standard communication strategies in healthcare?

    <p>They need to encourage comprehensive information delivery</p> Signup and view all the answers

    Which of the following measures does NQF endorse as a part of its standards-setting role?

    <p>Composite and resource use measures</p> Signup and view all the answers

    What is a limitation noted regarding the correlation between safety culture measures and patient safety outcomes?

    <p>There is no established link to improvements in patient outcomes</p> Signup and view all the answers

    In evaluating safety culture, which aspect must hospitals consider when conducting their surveys?

    <p>High-risk patient safety units must be included</p> Signup and view all the answers

    Which of the following describes a primary function of NQF's Measure Applications Partnership?

    <p>Advising on optimal measures for payment programs</p> Signup and view all the answers

    Study Notes

    Proactive Risk Assessment

    • Setup:

      • Define safety objectives and topics precisely.
      • Clearly delineate studied processes, distinguishing between routine and actual work. If there's a difference between "prescribed work" and "real work," the objective needs to account for this difference.
      • Identify the relevant context (organization, setting).
      • Prepare necessary resources for the assessment.
        • Use a checklist to guide analysis.

    • Do:

      • Select suitable evidence-based methods (e.g., FMEA).
      • Recruit a diverse team of participants, including a wide variety of individuals in the process.
      • Schedule meetings with clear parameters (frequency, duration).
      • Analyze failure modes, impacts, severities, and contributing factors.
      • Simulate failures to identify potential issues.
      • Develop and evaluate short- and long-term solutions, including recovery processes.
        • Use event tree analysis (ETA) and Failure Mode and Effects Analysis (FMEA).

    • Results:

      • Select appropriate scoring systems.
      • Establish metrics for measuring success.
      • Determine methods for evaluating the proactive risk assessment's effectiveness.
        • Use a checklist to guide the analysis

    Proactive Risk Assessment for Adverse Events

    • Event tree analysis: Used to assess mental health risks of ED patients, understanding risk presented by substance use issues.
    • Hazard identification of patient-owned equipment: Used after a post-surgical hospital incident related to patient-owned equipment. Assessment indicated a potential risk and led one hospital to bar certain equipment. A hazard identification checklist was used.
    • FMEA of interhospital patient transfers: Evaluates safety in transferring patients to different community hospitals, addressing issues related to handoffs and patient safety during transfers. This includes diagnostic imaging or other procedures. Process mapping can aid in identifying and assessing these handoffs. The results were documented on a checklist. Use a checklist to organize this.
    • Identify the scope or processes to be assessed: Carefully differentiate between "prescribed work" and "actual work" to fully consider potential differences and complete the assessment. A risk assessment checklist can guide the analysis.
    • Understand the risk presented by ED patients with mental health or substance use issues: Proactive risk assessments identify and address these issues, including substance use concerns and mental health-related risks. This includes training and safety protocols for mental health and behavior management.
    • Hospital patients often must be transferred to another community hospital for services (such as diagnostic imaging) and then return: This entails many handoffs and associated patient safety issues; a fault tree analysis or flow chart can assist with identifying and analyzing sequential possibilities of events. Process mapping can aid in identifying and assessing these handoffs. Document this assessment on a checklist—or use another form organized as a checklist to document the results.
    • Proactive risk assessment methods, such as event tree analysis (ETA) and Failure Mode and Effects Analysis (FMEA) are important for assessing risks. A checklist can guide the analysis.
    • Hospital incidents should be analyzed and documented. Develop a review process (risk assessment) to evaluate the incident. Use checklists to guide the analysis.

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    Description

    This quiz covers the essential elements of proactive risk assessment, including setup, execution, and evaluation phases. It emphasizes the importance of safety objectives, team participation, and the use of evidence-based methods. Understand how to analyze failure modes and apply scoring systems to measure the effectiveness of your assessments.

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