NURS-318: Professional Identity 1 (Exam 2)

What is an Electronic Health Record (EHR)?

A centralized digital system that stores and provides access to patient health information across healthcare settings

What is the primary purpose of Electronic Health Records (EHRs) in nursing?

To improve access to patient data, enhance coordination of care, and support clinical decision-making

What is Computerized Provider Order Entry (CPOE)?

A system that allows providers to enter medical orders electronically to reduce errors

How does Computerized Provider Order Entry (CPOE) improve patient safety?

It reduces handwriting errors, standardizes orders, and minimizes transcription mistakes

What is Barcode Medication Administration (BCMA)?

A system that uses barcode scanning to verify medications and patient identity before administration

How does Barcode Medication Administration (BCMA) enhance medication safety?

It ensures the “five rights” of medication administration (right patient, drug, dose, route, time)

What are telehealth platforms?

Technologies that enable remote patient monitoring, consultations, and healthcare delivery

What is the benefit of telehealth in nursing care?

It improves access to care, especially for patients in remote or underserved areas

What are mobile health (mHealth) apps?

Applications that support patient education, health tracking, and self-management

How do mobile health apps support nursing care?

They empower patients to manage their health and improve adherence to treatment plans

How do informatics improve patient safety?

By providing real-time access to accurate patient data

What are Clinical Decision Support Systems (CDSS)?

Tools that provide evidence-based recommendations to guide clinical decisions

How do Clinical Decision Support Systems (CDSS) improve patient outcomes?

They help clinicians follow best practices and reduce errors

What type of alerts do informatics systems provide?

Alerts for medication interactions, allergies, and potential risks

How does data analytics contribute to patient safety?

It identifies trends, risks, and patterns that can prevent adverse effects

How does informatics support clinical decision-making?

By integrating evidence-based guidelines into workflows

How does informatics enhance interprofessional communication?

It allows shared access to patient data across healthcare teams

How does informatics improve care planning?

It increases the timeliness and accuracy of clinical decisions

How does informatics support population health management?

By analyzing large data sets to identify community health trends

What law protects patient privacy in healthcare?

HIPAA (Health Insurance Portability and Accountability Act)

What is patient confidentiality?

The obligation to protect patient health information from unauthorized access

Why is data security important in healthcare?

To prevent breaches and protect sensitive patient information

What is a data breach?

Unauthorized access or disclosure of protected health information (PHI)

What is informed consent in telehealth?

Ensuring patients understand and agree to the use of digital healthcare technologies

What ethical concern is associated with technology in healthcare?

Bias in technology-driven decision-making

How can nurses uphold ethical standards when using technology?

By maintaining privacy, ensuring security, and using unbiased clinical judgment

What is essential for proper documentation in Electronic Health Records (EHRs)?

Accuracy and timeliness of entries

Why is accurate documentation critical in nursing?

It ensures continuity of care and legal protection

How can nurses maintain confidentiality when using shared devices?

By logging out, securing passwords, and avoiding unauthorized access

What is an example of applying informatics to medication safety?

Using Barcode Medication Administration (BCMA) to verify medications before administration

How should nurses use telehealth ethically?

By ensuring patient consent, privacy, and appropriate use of technology

A nurse forgets to log out of a shared computer. What principle is violated?

Patient confidentiality/data security

A system alerts a nurse to a medication allergy. What informatics tool is being used?

Clinical Decision Support System (CDSS)

A nurse scans a medication barcode before administration. What system is this?

Barcode Medication Administration (BCMA)

What is a primary responsibility of nurses in promoting patient safety?

Actively monitoring and assessing patient status to detect early signs of deterioration

How do nurses reduce patient risk during routine care?

By identifying potential hazards and taking preventative measures

Why is adherence to evidence-based protocols essential for safety?

It reduces variability in care and lowers the risk of preventable errors

How do nurses involve patients in safety efforts?

By educating patients and families and encouraging them to participate in care decisions

What is the nurse’s responsibility when noticing a safety concern?

Report concerns promptly and accurately

How does early recognition of patient changes improve outcomes?

It allows timely intervention before complications worsen

Why is documentation considered part of patient safety?

Accurate documentation ensures continuity of care and prevents miscommunication

How do nurses contribute to a culture of safety on healthcare teams?

By speaking up about risks and advocating for safe practices

What are human factors that contribute to safety events?

Fatigue, stress, and cognitive overload

How does fatigue increase risk for patient harm?

It reduces attention, decision-making ability, and reaction time

Why are communication breakdowns a major cause of safety events?

They lead to incomplete or inaccurate transfer of patient information

How does inadequate staffing affect patient safety?

It increases workload and reduces monitoring time per patient

What is meant by poor skill mix in staffing?

Having staff whose training level does not match patient care needs

How can equipment failures contribute to safety events?

Malfunctioning devices may delay treatment or cause incorrect interventions

Why is technology misuse a patient safety concern?

Incorrect use can lead to medication errors or inaccurate monitoring

How does lack of standardized procedures increase errors?

It creates inconsistencies in care delivery

What type of error is most likely when providers assume information rather than verify it?

Communication-related safety errors

What standardized communication tool improves patient safety during handoffs?

SBAR (Situation, Background, Assessment, Recommendation)

What is the purpose of SBAR communication?

To ensure structured, concise, and complete information exchange

Why is respectful communication essential in healthcare teams?

It promotes trust and reduces misunderstandings

How does interprofessional collaboration improve safety?

It allows multiple perspectives to identify risks and solutions

What is a “culture of safety”?

An environment where staff feel supported when reporting errors or concerns

Why should near-misses be reported?

They help prevent future adverse events

What role does teamwork play during emergencies?

It improves coordination and response efficiency

Why is timely reporting of adverse events important?

It enables investigation and system improvement

How does open communication reduce sentinel events?

It ensures critical information is shared promptly

What organization establishes the National Patient Safety Goals (NPSGs)?

The Joint Commission

What is the purpose of the National Patient Safety Goals?

To improve safety in accredited healthcare organizations

What role does Centers for Medicare and Medicaid Services (CMS) play in patient safety?

It supports quality initiatives tied to reimbursement and performance

What is the focus of the World Health Organization (WHO) Patient Safety Solutions?

Reducing global patient harm through standardized safety practices

What are the Institutes for Healthcare Improvement (IHI) safety bundles?

Evidence-based sets of interventions that improve patient outcomes when implemented together

How do safety bundles reduce complications?

They standardize best practices across care settings

How can standardized handoff communication prevent errors?

It ensures essential patient information is transferred consistently

Which national safety initiative supports improving transitions of care communication?

Joint Commission National Patient Safety Goals

A nurse uses SBAR during shift report to prevent omitted patient information. Which safety framework is being applied?

National Patient Safety Goals communication standards

A hospital implements infection-prevention bundles across units. Which organization’s strategy does this reflect?

Institute for Healthcare Improvement (IHI)

What is the first step when analyzing a patient safety scenario?

Identify safety risks present in the situation

What types of contributing factors should be evaluated in a safety scenario?

Staffing, communication, and environmental conditions

Why is identifying contributing factors important in safety analysis?

It helps determine why the event occurred and how to prevent recurrence

What actions should nurses take immediately after recognizing a safety risk?

Implement interventions to mitigate patient harm

What distinguishes immediate safety actions from long-term prevention strategies?

Immediate actions reduce current harm; long-term strategies prevent future events

A nurse notices unclear medication labeling on two similar vials. What type of safety risk is this?

A medication error risk related to packaging similarity

A unit is short-staffed and patients are not reassessed on time. What contributing facto