You are educating clinical managers in your healthcare facility on how to identify
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appropriate events for conducting a Root Cause Analysis. Which event provides the
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best opportunity for an RCA? - answer-a. A post-op patient removes his own IV causing
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a skin tear from the tape
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b. A patient with no known allergies experiences an anaphylactic reaction to an
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antibiotic requiring transfer to ICU.
b b b b b b
c. The biopsy samples from a colonoscopy are never received by pathology after the
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procedure
b
d. There have been 3 occurrences of depressed respirations in the same department in
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the last 4 months related to sedation
b b b b b b b
The answer is C. The biopsy samples from a colonoscopy are never received by
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pathology after the procedure - answer-
b b b b b b
The instrument count is incorrect at the conclusion of a surgical procedure. The hospital
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policy does not stipulate that the surgeon remain on the premises until an x-ray is
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obtained. The surgeon leaves the hospital to catch a flight. The x-ray reveals a retained
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instrument. Another surgeon is contacted to remove the retained instrument. What
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should leadership do next? - answer-a. Create a process map of how instruments are
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managed during surgery looking for latent flaws
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b. Revise the hospital policy to make it clear that surgeons must stay in the OR until
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instrument count issues are resolved
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c. Counsel the surgeon about customary clinical standards for a surgeon using
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appropriate accountability system
b b b
d. Reeducate the OR nursing staff on keeping track of instruments on the sterile field
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The answer is C. Counsel the surgeon about customary clinical standards for a surgeon
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using appropriate accountability system - answer-
b b b b b b
, A nurse on a medical-surgical unit does not comply with barcode medication
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administration (BCMA) while caring for one of her patients. What should her supervisor
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do? - answer-a. Ask staff if there are adequate scanners to meet their needs
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b. Counsel the nurse on the importance of following policy
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c. Request that the pharmacy run a report of BCMA compliance rates of the unit
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d. Ask the nurse what was occurring at the time, and why she chose to bypass the
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policy
b
The answer is D. Ask the nurse what was occurring at the time, and why she chose to
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bypass the policy - answer-
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The Board of Hospital A wants to know how Hospital A's safety performance in central
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line associated blood stream infection (CLABSI) compares to that of other hospitals in
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their region. Which data display would best inform them for that decision? - answer-a.
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Control charts of overall infection rate by quarter for the past two years for each
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hospital in the region
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b. A table indicating the CLABSI infection rates of all hospitals in the region relative to
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the National Healthcare Safety Network benchmark for CLABSI infections for the past 2
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years
b
c. A written report summarizing the current CLABSI prevention protocols of each
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hospital in the region
b b b b
d. A table showing the number of CLABSI infections in each hospital in the region by
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quarter for the past 2 years
b b b b b b
The answer is B. A table indicating the CLABSI infection rates of all hospitals in the
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region relative to the National Healthcare Safety Network benchmark for CLABSI
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infections for the past 2 years - answer-
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Your organization utilizes a "home grown" electronic safety event reporting system that
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is no longer meeting the needs of the organization. Hospital administration is asking for
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your opinion for next steps. What next steps would you take to identify a replacement
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system? - answer-a. Ask information systems to either fix the old one or build a new
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one
b
b. Identify key stakeholders and perform a gap analysis of current state to ideal state
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c. Poll colleagues and purchase what they use
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d. Purchase the lease expensive software and grow with it
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