Event and Errors
Identify the type of error: A physician forgets to follow-up lab test results after increasing the dose of a blood pressure medication for a patient who subsequently developed electrolyte abnormalities.
A. Lapse
B. Mistake
C. Slip
D. Violation
What is lapse (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)
In a QI project to reduce influenza infections in a health system population, what type of quality measure is rate of influenza infections?
A. Structural
B. Process
C. Outcome
D. Balancing
What is Outcome? (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)
Which of the following represents a SMART aim statement?
A. Increase HIV screening among uninsured patients to detect early infection.
B. Improve the percentage of uninsured patients with at least one lifetime HIV screening test to 100% by offering free screenings.
C. Improve the percentage of uninsured patients with at least one lifetime HIV screening test by 20% by December 31 of this year.
D. Improve the rate of HIV detection in uninsured patients by offering free screenings.
What is "Improve the percentage of uninsured patients with at least one lifetime HIV screening test by 20% by December 31 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 physician prescribed a medication to which a patient is allergic resulting in hives. Information about a previous allergic reaction was not available at the time.
A. Preventable adverse event
B. Negligent adverse event
C. Near miss
D. Malpractice
What is Preventable adverse event? (A)
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 the most effective for this team?
A. IHI Model for Improvement (PDSA)
B. Lean
C. Theory of Constraints
D. Six Sigma
What is IHI Model for Improvement (PDSA)? (A)
In a QI project to reduce influenza infections in a health system population, what type of quality measure is influenza vaccination rate?
A. Structural
B. Process
C. Outcome
D. Balancing
What is Process? (B)
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)
Identify the type of error: A pharmacist noticed that an order for hydrochlorothiazide was filled with hydrocortisone instead. This was corrected before administration to the patient.
A. Preventable adverse event
B. Negligent adverse event
C. Near miss
D. Malpractice
What is Near Miss? (C)
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)
In a QI project to reduce influenza infections in a health system population, what type of quality measure is number of vaccination clinics?
A. Structural
B. Process
C. Outcome
D. Balancing
What is Structural? (A)
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 QI team implemented EHR pop-up reminders for annual foot exams in diabetic clinic patients after identifying low baseline rates. According to the Plan-Do-Study-Act paradigm, the most appropriate subsequent action is:
A. Follow the patients with diabetes mellitus for one year to ensure that a significant number of charts are reviewed.
B. Measure the proportion of patients with diabetes mellitus that have foot exams 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.
What is measure the proportion of patients with diabetes mellitus that have foot exams 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)
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)
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 data source most commonly used for measures of patient experience is:
A. Administrative data
B. Electronic health records
C. Registries
D. Surveys
What are Surveys? (D)
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 implementing EMR pop-up reminders for annual foot exams in diabetic clinic patients, a QI team assessed the number of exams performed and then added educational modules to further increase rates. What step in the Plan-Do-Study-Act paradigm does this represent?
A. Plan
B. Do
C. Study
D. Act
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)
A physician forwarded an order for lab tests for a patient after increasing the dose of a blood pressure medication, however, the tests were not completed. Which of the following would be the most appropriate step in evaluating active and latent failures for this case?
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)
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)
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)
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)