Event and Errors
Identify the type of error: Lab results listed in Stan Smith’s electronic health record actually belong to Sam Smith, however, both patients were discharged to home yesterday.
A. Preventable adverse event
B. Negligent adverse event
C. Near miss
D. Malpractice
What is near miss? (C)
Which QI model best fits this scenario: Hospitals within a health system use different criteria when admitting obstetric patients for delivery that complicate care provided by physicians covering multiple hospitals.
A. Plan-Do-Study-Act (Model for Improvement)
B. Lean
C. Six Sigma
D. Clinical Decision Support
What is Six Sigma? (C)
Completing a surgical safety checklist prior to an invasive procedure is an example of:
A. Clinical Decision Support
B. Voluntary reporting system
C. Mandatory reporting system
D. Constraint
What is constraint? (D)
The first step of the Improvement Framework (problem scoping), includes all but one of the following:
A. Aim development
B. Team assembly
C. Problem identification
D. Measuring success
What is team assembly? (B)
In a QI project to reduce post-surgical infections, what type of quality measure is rate of post-surgical infections?
A. Structural
B. Process
C. Outcome
D. Balancing
What is outcome? (C)
Identify the type of error: A nurse did not check a patient’s ID band as required and the wrong patient was given iv insulin resulting in a symptomatic hypoglycemic episode that resolved with treatment.
A. Preventable adverse event
B. Negligent adverse event
C. Near miss
D. Malpractice
What is negligent adverse event? (B)
Which QI method best fits this scenario: An inpatient trauma unit wants to reduce opioid prescribing without compromising pain treatment.
A. Plan-Do-Study-Act (Model for Improvement)
B. Lean
C. Six Sigma
D. Clinical Decision Support
What is Plan-Do-Study-Act (Model for Improvement) ? (A)
The statement, “the patient has a history of diabetes,” refers to which component of the SBAR communication tool?
A. “S”
B. “B”
C. “A”
D. “R”
What is “B” (background)? (B)
Where in the Improvement Framework would a root cause/event analysis occur?
A. Problem scoping
B. System understanding
C. Intervention identification
D. Implementation planning
What is System understanding? (B)
In a QI project to reduce post-surgical infections, what type of quality measure is adherence with a surgical antibiotic protocol?
A. Structural
B. Process
C. Outcome
D. Balancing
What is process? (B)
Identify the type of error: A physician prescribed a medication to which a patient is allergic resulting in hives. The allergy was not listed in the patient’s record although it had been experienced before.
A. Preventable adverse event
B. Negligent adverse event
C. Near miss
D. Malpractice
What is a preventable adverse event? (A)
Which QI method best fits this scenario: 10% of lab tests run in an outpatient lab require repeating because of misprocessing, errors, and machine malfunction.
A. Plan-Do-Study-Act (Model for Improvement)
B. Lean
C. Six Sigma
D. Clinical Decision Support
What is Lean? (B)
Which concept best describes the scenario where a patient receives the wrong medication?
A. Latent error
B. Blunt end failure
C. System defenses
D. Hole in the Swiss cheese
What is Hole in the Swiss cheese? (D)
Where in the Improvement Framework would the “Do” part of the PDSA cycle occur?
A. Intervention identification
B. Implementation planning
C. Implementation modification
D. Pilot implementation plan
What is pilot implementation plan? (D)
In a QI project to reduce post-surgical infections, what type of quality measure is nurse-to-patient ratio?
A. Structural
B. Process
C. Outcome
D. Balancing
What is structural? (A)
Forgetting to record a patient’s drug allergy characterizes what type of intent related to medical errors?
A. Lapse
B. Mistake
C. Slip
D. Violation
What is lapse? (A)
Methods of root cause or event analysis include all the following except:
A. Clinical pathways
B. Process map
C. Cause-and-effect diagram
D. Key driver diagram
What are clinical pathways? (A)
The largest international accrediting body for health care organizations is the:
A. Institute of Health
B. National Quality Forum
C. Joint Commission
D. World Health Association
What is Joint Commission? (C)
Where in the Improvement Framework would the “Act” part of the PDSA cycle occur?
A. Intervention identification
B. Implementation planning
C. Implementation modification
D. Pilot implementation plan
What is implementation modification? (C)
The data source most commonly used for measures of patient experience.
A. Administrative data
B. Electronic health records
C. Registries
D. Surveys
What is surveys? (D)
Patient death or serious injury associated with use of a medical device during hospitalization is an example of:
A. Preventable adverse event
B. Latent error
C. Procedural error
D. Sentinel event
What is sentinel event? (D)
SMART is an acronym for a goal setting framework that means:
A. Specific, Meaningful, Attainable, Relevant, and Tangible
B. Specific, Measurable, Attainable, Reliable, and Time-bound
C. Specific, Measurable, Attainable, Relevant, and Time-bound
D. Specific, Meaningful, Attainable, Reliable, and Tangible
What is Specific, Measurable, Attainable, Relevant, and Time-bound? (C)
The six dimensions of quality are:
A. Safe, timely, effective, economical, equitable, and practiced
B. Safe, timely, effective, economical, equitable, and patient centered
C. Safe, timely, effective, efficient, equitable, and patient centered
D. Safe, timely, effective, efficient, equitable, and practiced
What are safe, timely, effective, efficient, equitable, and patient centered ? (C)
The QI team collects data for six months after implementing an intervention to improve newborn hearing rates. What steps in the Improvement Framework are next?
A. Implementation assessment; implementation modification, scale and spread
B. Implementation assessment; implementation planning, scale and spread
C. Implementation assessment; pilot implementation plan, implementation modification
D. Implementation assessment; implementation modification, pilot implementation plan
What are implementation assessment; implementation modification, scale and spread? (A)
Sources of publicly reported measures include all the following except:
A. Institute for Healthcare Improvement
B. Centers for Medicare & Medicaid Services (CMS)
C. The Joint Commission National Patient Safety Goals
D. AHRQ Patient Safety Indicators
What is Institute for Healthcare Improvement? (A)