A patient safety professional is advocating that a quarterly summary of safety events be
1
distributed to hospital staff at large. Legal counsel is concerned about potential liability
and adverse media coverage. Which of the following is the most compelling argument for
sharing findings?
A. The media will view event reporting in a positive light.
B. The events to be shared reflect adherence to the standard of care and therefore
pose minimal vulnerability for legal action.
C. The leadership of the hospital rewards staff for reporting events.
D. Sharing findings with hospital staff promotes awareness of risks to patients and
reduces complacency.
Which of the following is the best sequence of steps when selecting an event reporting
2
system?
A. Evaluate available options, pilot selected options, and obtain user feedback.
B. Identify the vendor used by a neighboring hospital, solicit a proposal from that
vendor, and implement system.
C. Design curriculum for end users, invite the vendor to present educational
sessions, and offer online tutorials.
D. Create reports needed for end users, establish accountability for reporting, and
guide teams in action planning.
Multiple nurses have reported that a physician’s behavior is disruptive. An effective first
3
step in responding to the nurses' concern is to
A. counsel the physician.
B. terminate the privileges of the physician.
C. refer the case to a physician impairment committee.
D. interview the physician.
A medical assistant used a small blood pressure cuff on a patient who is morbidly obese
4
with hypertension, resulting in an inappropriate increase in anti-hypertensive
medications. In a follow-up visit for severe diarrhea as a side effect of the new anti-
hypertensive medication, which of the following conversations by the healthcare
provider includes the most appropriate elements for patient disclosure of the medical
error?
A. "Your diarrhea is probably related to the new anti-hypertensive medicine that we
prescribed for you last week. We are going to stop the new medication, which
should clear up the diarrhea. Do you have any questions?"
B. "Our medical assistant used the wrong size of blood pressure cuff so we changed
, your medication, and that is what is causing your diarrhea. I will stop the new
medication and that should clear up your diarrhea. I am very sorry this
happened."
C. "I think your diarrhea is from the new blood pressure medicine that I prescribed
because a staff member used the wrong size blood pressure cuff. I am very sorry
this happened and that you had to suffer the consequences of having a reaction
to the medicine."
D. "We have identified that the wrong size of blood pressure cuff was used, which
resulted in a prescription for a new medication. The new medication is most likely
causing your diarrhea. I am very sorry that you had these unnecessary side
effects. We have a new process to prevent this from occurring again. Do you have
any questions?"
In January of 2009 a hospital implemented a bar-code system using handheld technology
5
at the bedside to verify the right patient, drug, dose, time and route for safe medication
administration. They trended their system warnings to detect medication system
opportunities related to wrong patient. The results are as follows:
Based on data generated from the bar-code medication system, which of the following is
the best conclusion?
A. The system has failed to produce a sustainable reduction in wrong-patient events,
and removal should be considered.
B. The data do not provide sufficient evidence to judge the effectiveness of the
system.
C. There are adequate data points to support the implementation of a system-wide
change in the bar-code medication system.
D. Based on the trend over time, it can be predicted that a 20% reduction in the
wrong-patient events is expected.
1
distributed to hospital staff at large. Legal counsel is concerned about potential liability
and adverse media coverage. Which of the following is the most compelling argument for
sharing findings?
A. The media will view event reporting in a positive light.
B. The events to be shared reflect adherence to the standard of care and therefore
pose minimal vulnerability for legal action.
C. The leadership of the hospital rewards staff for reporting events.
D. Sharing findings with hospital staff promotes awareness of risks to patients and
reduces complacency.
Which of the following is the best sequence of steps when selecting an event reporting
2
system?
A. Evaluate available options, pilot selected options, and obtain user feedback.
B. Identify the vendor used by a neighboring hospital, solicit a proposal from that
vendor, and implement system.
C. Design curriculum for end users, invite the vendor to present educational
sessions, and offer online tutorials.
D. Create reports needed for end users, establish accountability for reporting, and
guide teams in action planning.
Multiple nurses have reported that a physician’s behavior is disruptive. An effective first
3
step in responding to the nurses' concern is to
A. counsel the physician.
B. terminate the privileges of the physician.
C. refer the case to a physician impairment committee.
D. interview the physician.
A medical assistant used a small blood pressure cuff on a patient who is morbidly obese
4
with hypertension, resulting in an inappropriate increase in anti-hypertensive
medications. In a follow-up visit for severe diarrhea as a side effect of the new anti-
hypertensive medication, which of the following conversations by the healthcare
provider includes the most appropriate elements for patient disclosure of the medical
error?
A. "Your diarrhea is probably related to the new anti-hypertensive medicine that we
prescribed for you last week. We are going to stop the new medication, which
should clear up the diarrhea. Do you have any questions?"
B. "Our medical assistant used the wrong size of blood pressure cuff so we changed
, your medication, and that is what is causing your diarrhea. I will stop the new
medication and that should clear up your diarrhea. I am very sorry this
happened."
C. "I think your diarrhea is from the new blood pressure medicine that I prescribed
because a staff member used the wrong size blood pressure cuff. I am very sorry
this happened and that you had to suffer the consequences of having a reaction
to the medicine."
D. "We have identified that the wrong size of blood pressure cuff was used, which
resulted in a prescription for a new medication. The new medication is most likely
causing your diarrhea. I am very sorry that you had these unnecessary side
effects. We have a new process to prevent this from occurring again. Do you have
any questions?"
In January of 2009 a hospital implemented a bar-code system using handheld technology
5
at the bedside to verify the right patient, drug, dose, time and route for safe medication
administration. They trended their system warnings to detect medication system
opportunities related to wrong patient. The results are as follows:
Based on data generated from the bar-code medication system, which of the following is
the best conclusion?
A. The system has failed to produce a sustainable reduction in wrong-patient events,
and removal should be considered.
B. The data do not provide sufficient evidence to judge the effectiveness of the
system.
C. There are adequate data points to support the implementation of a system-wide
change in the bar-code medication system.
D. Based on the trend over time, it can be predicted that a 20% reduction in the
wrong-patient events is expected.
