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.
What is near miss?
A QI model that 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.
What is Six Sigma?
Completing a surgical safety checklist prior to an invasive procedure is an example of:
What is a constraint?
The first step of the Improvement Framework (problem scoping) includes all but one of the following: Aim development, Team assembly, Problem identification, Measuring success.
What is team assembly?
The type of quality measure for rate of post-surgical infections in a QI project to reduce post-surgical infections.
What is outcome?
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.
What is negligent adverse event?
A QI method best fits this scenario: An inpatient trauma unit wants to reduce opioid prescribing without compromising pain treatment.
What is the Plan-Do-Study-Act (Model for Improvement)?
The component of the SBAR communication tool that the statement, “the patient has a history of diabetes,” refers to.
What is background?
The step of the Improvement Framework where a root cause/event analysis occurs.
What is system understanding?
The type of quality measure for adherence with a surgical antibiotic protocol in a QI project to reduce post-surgical infections.
What is process?
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.
What is preventable adverse event?
A QI method best fits this scenario: 10% of lab tests run in an outpatient lab require repeating because of misprocessing, errors, and machine malfunction.
What is Lean?
A concept that best describes the scenario where a patient receives the wrong medication.
What is a hole in the Swiss cheese?
The step of the Improvement Framework where the “Do” part of the PDSA cycle occurs.
What is a pilot implementation plan?
The type of quality measure for nurse-to-patient ratio in a QI project to reduce post-surgical infections.
What is structural?
Forgetting to record a patient’s drug allergy characterizes this type of intent underlying a preventable adverse event.
What is a lapse?
Methods of root cause or event analysis include all the following except: Clinical pathways, Process map, Cause-and-effect diagram, Key driver diagram.
What are clinical pathways?
The largest international accrediting body for health care organizations.
What is The Joint Commission?
The step of the Improvement Framework where the “Act” part of the PDSA cycle occurs.
What is implementation modification?
The data source most commonly used for measures of patient experience.
What are surveys?
Patient death or serious injury associated with use of a medical device during hospitalization is an example of:
What are sentinel events?
SMART is an acronym for a goal setting framework that means:
What is Specific, Measurable, Attainable, Relevant, and Time-bound?
The six dimensions of quality.
What is Safe, timely, effective, efficient, equitable, and patient centered (STEEEP)?
The step of the Improvement Framework that occurs after the QI team collects data for six months after implementing an intervention to improve newborn hearing rates.
What is implementation assessment; implementation modification, scale and spread?
Sources of publicly reported measures include all the following except: Institute for Healthcare Improvement, Centers for Medicare & Medicaid Services (CMS), The Joint Commission National Patient Safety Goals, AHRQ Patient Safety Indicators.
What is the Institute for Healthcare Improvement?