Daily safety huddle
Error
Fair and just culture
Financial performance
FMEA
Hierarchy
HRO
Human factors
Interprofessional
Knowledge‐based performance
Latent errors
Learning organization
Marketing plan
Near miss safety event
Organizational culture
Patient‐centered care
Precursor safety event
QSEN
Quality
Reliability
Root cause analysis
Rule‐based performance
Safety
SBAR
Sentinel event
Serious safety event
Sharp end
Skill‐based performance
Strategic planning
Swiss Cheese model
Teamwork
Transparency
Work‐around
REVIEW QUESTIONS
1 The nurse administers insulin to the wrong patient. The nurse should (select all that apply):Monitor the patient closelyReport the error to the patient's physicianResign from the hospitalComplete an error report
2 A nurse leader makes frequent and regular rounds to nursing units and talks to staff about patient safety. The nurse leader is most likely rounding to:Criticize the safety practices of nurses and other cliniciansLook for weaknesses in the care delivery system that allow errors to occurConduct an FMEARally the troops for the next strategic initiative
3 The delivery of health care is largely based on rules, often called protocol. Nurse leaders need to track data on staff compliance with rule‐based performance because:Nurses frequently experience slips, lapses, and fumblesThis will help them to punish nurses who make errorsNurses forget to double check each other's workThis will help them to look for ways to improve practice
4 The continuous, systematic process of making decisions today with the greatest possible knowledge of their effects on the future is the definition of:Mission, vision, and valuesStrategic planningRoot cause analysisSWOT analysis
5 A just culture creates an atmosphere of trust because it (select all that apply):Never punishes clinicians for their behaviorsEncourages and rewards people for providing essential safety‐related informationViews errors as opportunities to improve health care system risksViews errors as opportunities to improve individual behavioral riskMakes only managers responsible for reporting errorsMakes everyone responsible for identifying safety risks
6 The nurse behaves in one way when her manager and peers are watching and another way when she believes she is not being observed. She is demonstrating:Intrinsic accountabilityHorizontal and vertical accountabilityIntrinsic and horizontal accountabilityVertical accountability
7 An organization may regularly administer a culture of safety survey to (select all that apply):Identify areas of patient safety strengthsIncrease staff awareness about patient safetyHighlight areas of opportunity for patient safety culture improvementExamine trends in patient safety culture over timeEvaluate the impact of specific interventions
8 Key components of the Magnet Model include (select all that apply):Transformational leadershipExemplary Professional PracticeInformation TechnologyStructural EmpowermentTeamwork and CollaborationNew Knowledge, Innovations, and ImprovementsEmpirical outcomes
9 The Institute for Healthcare Improvement uses the PDSA cycle for small, rapid‐cycle tests of change. PDSA is an acronym for:Plan‐Develop‐Start‐ActPlan‐Do‐Study‐ActPrepare‐Do‐Select‐AcquirePrepare‐Develop‐Stop‐Ask
10 The Centers for Medicare and Medicaid tie financial incentives to reliability through pay for performance programs. These programs include (select all that apply):Value‐based purchasingHospital report card actHospital readmission reduction penaltyHospital‐acquired conditions reduction
REVIEW QUESTION ANSWERS
1 The correct response is: A, B, CRationale:Monitor the patient closely—Correct. It's important to monitor this patient for signs and symptoms of hypoglycemia.Report the error to the patient's physician—Correct. The physician needs to be aware of this error so that the medical treatment plan can be appropriately adjusted.Resign from the hospital—No. Errors happen and need to be addressed and prevented in the future. However, resignation from the hospital because of an error is not appropriate.Complete an error report—Correct. An error report should be completed. This allows the error to be investigated and optimizes the chances of preventing similar errors in the future.
2 The correct response is: BRationale:Criticize the safety practices of nurses and other clinicians—No. The nurse leader rounds to look for safety opportunities, not to criticize clinicians.Look for weaknesses in the care delivery system that allow errors to occur Correct. Nurse leaders are looking for opportunities to improve the systems of care to enhance patient safety.Conduct an FMEA—No. An FMEA is conducted with an interprofessional team to proactively identify potential safety issues.Rally the troops for the next strategic initiative—No. The nurse leader is focusing on patient safety.
3 The correct response is: DRationale:Nurses frequently experience slips, lapses, and fumbles—No. These errors occur with skill‐based performance, not rule based performance.This will help them to punish nurses who make errors—No. Rather than punishing nurses who make errors, nurse leaders strive to create a fair and just culture.Nurses forget to double check each other's work—No. Double checking each other's work is an important tool used to prevent skill‐based errors.This will help them to look for ways to improve practice—Correct. Collecting and analyzing data on protocol compliance will help the nurse leader identify improvement opportunities.
4 The correct response is: BRationale:Mission, vision, and values—No. Mission, vision, and values guide an organization and are part of strategic planning.Strategic planning—Correct. Strategic planning is an ongoing effort to position an organization for the future.Root cause analysis—No. A Root Cause Analysis is an in‐depth investigation of a serious or sentinel safety event.SWOT analysis—No. A SWOT analysis examines strengths, weaknesses, opportunities, and threats as part of strategic planning.
5 The correct response is: B, C, D, FRationale:Never punishes clinicians for their behaviors—No. While a just culture minimizes blame and punishment, it holds people accountable for their actions. Blatant disregard for the rules is punished.Encourages and rewards people for providing essential safety‐related information—Correct. People are recognized and praised for speaking up about safety concerns.Views errors as opportunities to improve health care system risks—Correct. Errors are analyzed to determine what went wrong and corrections are made to improve the system.Views errors as opportunities to improve individual behavioral risk—Correct Errors are examined for human factors and processes are modified accordingly.Makes only managers responsible for reporting errors—No. Everyone is responsible for reporting errors.Makes everyone responsible for identifying safety risks—Correct. A just culture sets the expectation that everyone looks for risks in the environment, reports errors, helps design safe systems, and makes safe choices.
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