Professional And Population 2 - Exam 1
Call Kai
Learn
Practice Test
Spaced Repetition
Match
Flashcards
Knowt Play1/282
There's no tags or description
Looks like no tags are added yet.
Name | Mastery | Learn | Test | Matching | Spaced | Call with Kai | Chat |
|---|
No analytics yet
Send a link to your students to track their progress
283 Terms
Q: What is a medical error?
A: An unintended act or omission that occurs during the course of treatment and causes harm to the patient
Q: What is an adverse event?
A: An injury resulting from a medical intervention that may or may not have been preventable.
Q: What is a sentinel event?
A: A patient safety event that reaches the patient and results in death, permanent harm, or severe temporary harm requiring life-sustaining intervention.
Q: What should happen after a sentinel event?
A: It warrants immediate investigation and response, usually including a Root Cause Analysis (RCA).
Q: What is a near miss?
A: An error that could have caused patient harm but did not because it was intercepted or because of chance.
Q: What is another term for a near miss?
A: A “close call.”
Q: Should near misses be reported?
A: Yes. Near misses must be reported because they can reveal problems in the healthcare system before patient harm occurs.
Q: What is a never event?
A: A clearly identifiable, measurable, serious, and preventable adverse event that results in death or significant disability.
Q: What does CMS do regarding never events?
A: CMS will not pay for costs associated with certain preventable never events.
Q: What is an incident report?
A: A specific type of documentation completed after an error, near miss, or other unexpected occurrence during patient care.
Q: Is an incident report part of the patient's medical record?
A: No. An incident report is not included in the patient's medical record.
Q: What is the purpose of an incident report?
A: To identify process problems and areas that could benefit from safety and quality improvement.
Examples of Errors & Adverse Events
Q: What are common examples of nursing errors?
A: Medication errors, documentation errors, communication errors, and failures to follow safety procedures.
Q: What is one example of a medication error?
A: Failure to follow the 7 rights of medication administration.
Q: What are examples of healthcare-associated infections (HAIs)?
A: CAUTI, CLABSI, and VAP.
Q: What does CAUTI stand for?
A: Catheter-associated urinary tract infection.
Q: What does CLABSI stand for?
A: Central line-associated bloodstream infection.
Q: What does VAP stand for?
A: Ventilator-associated pneumonia.
Q: What is an example of a hospital-acquired pressure injury?
A: A pressure ulcer that develops after the patient is admitted to the hospital.
Q: What is an example of a blood-related adverse event?
A: A blood transfusion reaction.
Sentinel Events
Q: Give examples of sentinel events.
A: Wrong-site surgery, wrong-patient surgery, wrong-limb amputation, leaving surgical supplies inside a patient, medication errors resulting in death, and newborn abduction.
Q: Does a sentinel event have to be preventable?
A: No. A sentinel event may or may not have been preventable.
Q: What type of analysis is commonly performed after a sentinel event?
A: Root Cause Analysis (RCA).
Q: Are accredited organizations required to report sentinel events to The Joint Commission?
A: No. They are strongly encouraged to report them but are not required to do so.
Root Cause Analysis
Q: What is Root Cause Analysis (RCA)?
A: A structured investigation in which a multidisciplinary team analyzes the sequence of events leading to an error to determine how and why it occurred.
Q: What is the primary goal of RCA?
A: To prevent future harm by identifying and eliminating hidden system problems that contribute to adverse events.
Q: Who participates in an RCA?
A: A multidisciplinary team.
Q: What does RCA focus on besides the individual who made the error?
A: The systems, processes, environment, communication, equipment, and other factors that contributed to the error.
Q: Why is RCA important?
A: It helps healthcare organizations identify system problems and make changes to prevent similar errors from happening again.
Human Factors
Q: What are human factors in healthcare?
A: The relationships among people, the tools and equipment they use, and the environment in which they work.
Q: What does a human factors approach emphasize?
A: Looking beyond individual human error to identify system and environmental factors that contribute to mistakes.
Q: Give examples of human factors that can contribute to errors.
A: Similar-looking drug names, vague provider instructions, confusing equipment, barcode scanning problems, distractions, and poor workflow.
Never Events
Q: Give examples of never events.
A: Wrong-site or wrong-patient surgery, suicide in a healthcare setting, injury or death from contaminated devices or drugs, medication-error-related death, and death from improper restraint use.
Q: What makes a never event different from a general adverse event?
A: Never events are serious, clearly identifiable, measurable, and considered preventable.
Q: Can a never event result in death or significant disability?
A: Yes.
Near Misses
Q: Why are near misses important to report?
A: They identify safety problems before those problems result in patient harm.
Q: A nurse catches a medication error using barcode scanning before giving the medication. What is this?
A: A near miss.
Q: A surgical mistake is caught during the procedural “time out” before surgery begins. What is this?
A: A near miss.
Q: An RN catches an incorrect medication dose during a required double-check. What is this?
A: A near miss.
Error Reporting
Q: What is the first step when an error occurs?
A: Assess and stabilize the patient first.
Q: What information should be included when reporting an incident?
A: The date, time, location, people involved, and witnesses.
Q: How should a nurse describe an incident in an incident report?
A: With an objective, factual, step-by-step description of what happened before, during, and after the incident.
Q: Should nurses include their opinions in an incident report?
A: No. The report should contain objective and factual information.
Q: Should nurses use direct quotes when appropriate in an incident report?
A: Yes.
Q: Should nurses use jargon in an incident report?
A: No. Documentation should be clear and understandable.
Q: What injuries should be documented after an incident?
A: Any injuries sustained and the medical treatment or attention provided.
Q: Should damage to equipment or property be documented?
A: Yes.
Q: What interventions should be included in incident reporting?
A: Actions such as calling for help, notifying the provider, treating the patient, or securing the area.
Q: What are important documentation principles when reporting an error?
A: Objectivity, clarity, accuracy, and confidentiality.
Q: What should the nurse do after reporting an error?
A: Participate in follow-up procedures such as investigation, RCA when appropriate, and feedback processes.
Causes & Contributors to Errors
Q: What are common contributors to healthcare errors?
A: Inadequate communication, system failures, workflow problems, inadequate staffing, fatigue, stress, and distractions.
Q: How can inadequate communication contribute to errors?
A: Important patient information may be misunderstood, missed, or not communicated to the appropriate healthcare professional.
Q: How can inadequate staffing contribute to errors?
A: Increased workload and reduced time can contribute to fatigue, missed care, poor communication, and mistakes.
Q: How can fatigue contribute to errors?
A: Fatigue can decrease attention, concentration, decision-making, and reaction time.
Q: How can distractions contribute to errors?
A: They can interrupt concentration and cause important steps or information to be missed.
Q: How can workflow problems contribute to errors?
A: Poorly designed processes can make it easier for healthcare workers to make mistakes or bypass safety measures.
Importance of Error Reporting
Q: Why is error reporting important?
A: It improves future patient outcomes, identifies system problems, supports quality improvement, and promotes patient safety.
Q: How does error reporting support quality improvement?
A: It helps organizations identify patterns and system problems so processes can be changed to prevent future errors.
Q: How does error reporting support risk management?
A: It helps organizations identify and address risks before they result in additional patient harm.
Q: Why should a near miss be reported even if the patient was not harmed?
A: Because the near miss may reveal a system problem that could cause harm to another patient in the future.
Q: What does organizational transparency mean in patient safety?
A: Being open and honest about errors and safety problems while working to improve the system.
Regulatory & Accrediting Organizations
Q: What organization accredits healthcare organizations and focuses on patient safety?
A: The Joint Commission.
Q: What does CMS stand for?
A: Centers for Medicare & Medicaid Services.
Q: What federal agency regulates drugs, medical devices, and other health-related products?
A: The Food and Drug Administration (FDA).
Q: What organization focuses on workplace safety and health?
A: OSHA (Occupational Safety and Health Administration).
Q: What professional organization provides ethical guidance for nurses?
A: The American Nurses Association (ANA), including its Code of Ethics.
Culture of Safety
Q: What is a culture of safety?
A: The behaviors, beliefs, and values within an organization related to safety and clinical excellence.
Q: What are three important components of a culture of safety?
A: Just culture, reporting culture, and learning culture.
Q: What is a reporting culture?
A: A workplace culture where healthcare workers feel encouraged and able to report errors and near misses.
Q: Why should organizations make error reporting easy?
A: Easy reporting encourages staff to report safety concerns and increases opportunities to identify and fix system problems.
Q: What is a learning culture?
A: A culture that uses errors and near misses as opportunities to learn and improve patient safety.
Q: Why might healthcare workers fail to report an error?
A: They may believe that because no harm occurred, the error does not need to be reported.
Q: How can organizations increase risk awareness?
A: By encouraging reporting, educating staff, analyzing errors and near misses, and providing feedback about safety improvements.
Q: Why is feedback important after an error is reported?
A: It shows staff that their reports are taken seriously and helps them understand what changes were made to improve safety.
Q: Why should healthcare organizations offer support after an error?
A: Errors can have ethical, legal, professional, and emotional effects on healthcare workers, so support can help staff cope and learn.
Just Culture
Q: What is Just Culture?
A: An approach to safety that distinguishes between human error, at-risk behavior, and reckless behavior while promoting accountability and learning.
Q: What is a simple human error?
A: An unintended mistake where the person did not mean to make the error and was not aware they were making it.
Q: Give an example of a simple human error.
A: A nurse accidentally selects the wrong medication because two medications have similar packaging.
Q: What is at-risk behavior?
A: Behavior where a person takes a risk or bypasses a safety practice without fully appreciating the potential consequences.
Q: Give an example of at-risk behavior.
A: Overriding a medication safety alert or bypassing a required safety check.
Q: What is reckless behavior?
A: Conscious disregard of a substantial and unjustifiable risk.
Q: Give an example of reckless behavior.
A: A healthcare worker knowingly coming to work under the influence of drugs or alcohol.
Q: How should Just Culture respond to simple human error?
A: Focus on supporting the individual and improving the system to prevent the error from happening again.
Q: How should Just Culture respond to at-risk behavior?
A: Address the risky behavior through coaching, education, and changes that encourage safer choices.
Q: How should Just Culture respond to reckless behavior?
A: Hold the individual accountable because they knowingly disregarded a significant safety risk.
Ethical, Legal & Emotional Aspects
Q: What are three important aspects of medical errors for nurses to consider?
A: Ethical, legal, and emotional aspects.
Q: Why are errors an ethical issue for nurses?
A: Nurses have a responsibility to protect patients, provide safe care, be honest, and promote patient well-being.