Event and Errors
Identify the type of error: A patient was recently started on an increased dose of a blood pressure medication. The physician instructs the patient to go to the lab for bloodwork but forgets to order the labs. Several days later, the patient ends in the ED with electrolyte abnormalities.
A. Preventable adverse event
B. Negligent adverse event
C. Near miss
D. Malpractice
What is preventable adverse event? (A)
What is the usual order of the five steps of the Six Sigma Improvement cycle?
A. Define, measure, analyze, improve, control
B. Define, improve, measure, analyze, control
C. Analyze, improve, define, measure, control
D. Analyze, improve, define, measure, control
What is Define, measure, analyze, improve, control (A)
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)
Which of the following represents a SMART aim statement?
A. We will increase HIV screening among our uninsured patients to detect infection and offer HIV treatment sooner.
B. We will improve the percentage of our uninsured clinic patients who have had at least one lifetime HIV screening test to 100% by offering free screenings at several sites around the city.
C. We will improve the percentage of our uninsured clinic patients who have had at least one lifetime HIV screening test by 20% by December 31st of this year.
D. We will improve the rate of HIV detection in the uninsured population by offering free screenings at several sites around the city.
What is "We will improve the percentage of our uninsured clinic patients who have had at least one lifetime HIV screening test by 20% by December 31st of this year." (C)
Communication among health team members can be inhibited by:
A. Premature closure
B. Heuristic
C. Authority gradient
D. Normalization of deviance
What is authority gradient? (C)
Identify the type of error: A patient was recently started on an increased dose of a blood pressure medication. The physician instructs the patient to go to the lab for bloodwork but forgets to order the labs. Several days later, the patient ends in the ED with electrolyte abnormalities.
A. Lapse
B. Mistake
C. Slip
D. Violation
What is lapse? (A)
Which QI method best fits this scenario: A team at a small hospice unit wants to improve the process for management of end-of-life pain. They agree about the subject but need help to define an aim and appropriate metrics to measure success. Which quality improvement methodology would be most effective for this team?
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)
A telemetry unit frequently causes an alarm that is generally ignored by nursing staff. This demonstrates:
A. Premature closure
B. Heuristic
C. Authority gradient
D. Normalization of deviance
What is normalization of deviance? (D)
Which category fits this occurrence? A patient was recently started on an increased dose of a blood pressure medication. The physician instructs the patient to go to the lab for bloodwork but forgets to order the labs. Several days later, the patient ends in the ED with electrolyte abnormalities.
A. Memory lapse
B. Attention failure
C. Knowledge error
D. Cognitive error
What is memory lapse? (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)
A physician began a quality improvement project after treating a patient with diabetes mellitus who required a foot amputation due to advanced infection. The physician theorized that providing a reminder to conduct foot examinations through the EHR would increase the number of documented foot examinations. The EHR team developed and implemented pop up reminders regarding the need for foot examinations. According to the PDSA paradigm, which of the following is the most appropriate subsequent action?
A. Follow the patients with diabetes mellitus for one year to ensure a significant number of charts are reviewed
B. Measure the proportion of patients with diabetes mellitus that have foot examinations documented in their charts over the next three months
C. Organize a lecture about appropriate diabetic foot care for residents in addition to the reminders
D. Present the results of the initial chart review to hospital leadership
E. Repeat the chart review every six months until no further improvement is noted
What is measure the proportion of patients with diabetes mellitus that have foot examinations documented in their charts over the next three months? (B)
Second victims are:
A. Family members of the patient experiencing a medical error
B. Physicians and other health care professionals experiencing the impact of a medical error
C. The quality improvement team assigned to evaluate an error
D. Other patients receiving similar care in the health system
What is physicians and other health care professionals experiencing the impact of a medical error? (B)
A patient was recently started on an increased dose of a blood pressure medication. The physician instructs the patient to go to the lab for bloodwork but forgets to order the labs. Several days later, the patient ends in the ED with electrolyte abnormalities. The physician discusses the event with colleagues in the practice. The group would like to explore latent and active failures in this case. Which of the following would be the most appropriate next step?
A. Explore active failures by analyzing the structure of the office staff
B. Explore active failures by investigating the process of physician notification for missed lab appointments
C. Explore latent failures by investigating communication processes between physicians and office staff in the EHR.
D. Explore latent failures by reviewing the involved physician's charts in detail to determine the number of similar occurrences.
What is explore latent failures by investigating communication processes between physicians and office staff in the EHR (C)?
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)
After assessing the data of foot examinations performed after initiating pop-up reminders, the pop-up reminders were enhanced with educational modules to increase the performance and documentation of foot examinations in diabetic patients. What step in the PDSA cycle does this represent?
A. Plan
B. Do
C. Study
D. Act
E. None of these
What is Act? (D)
Name the type of bias: A patient with a history of pancreatitis presents with upper abdominal pain and the physician orders labs to diagnose recurrent pancreatitis. The labs are normal, and the patient is later diagnosed with an acute heart attack.
A. Commission
B. Confirmation
C. Aggregate
D. Regret
What is confirmation bias? (B)
Which of the following tools is likely to help a team understand the root causes that has led to the current state?
A. Five Whys
B. Fishbone diagram
C. SWOT
D. A and B
What is A and B (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)
Name that bias. A physician prescribes antibiotics for a viral infection that does not need antibiotic treatment.
A. Commission
B. Confirmation
C. Aggregate
D. Regret
What is commission bias? (A)