CPHQ Patient Safety Principles 3 — Questions and Answers
Question 1: Which framework specifically addresses human error in complex sociotechnical systems by categorizing failures as person-based or system-based?
- Donabedian Model
- James Reason's Human Error Model (Correct answer)
- FMEA
- PDSA Cycle
Correct answer: James Reason's Human Error Model
James Reason's model distinguishes between person-centered approaches (blame the individual) and system approaches (fix the organization).
Question 2: In a hospital, nurses routinely skip the two-patient identifier check because it slows workflow. Over time staff accept this as normal. This phenomenon is called:
- Cognitive bias
- Normalization of deviance (Correct answer)
- Latent failure
- Production pressure
Correct answer: Normalization of deviance
Normalization of deviance occurs when unsafe workarounds become accepted as the norm because no immediate harm results.
Question 3: Which element is REQUIRED for a valid informed consent process in the United States?
- Consent obtained only by a physician
- Patient's signature on a pre-printed form
- Disclosure of material risks, benefits, and alternatives (Correct answer)
- Consent obtained at least 24 hours before a procedure
Correct answer: Disclosure of material risks, benefits, and alternatives
Valid informed consent requires disclosure of material risks, benefits, and alternatives so the patient can make a voluntary, informed decision.
Question 4: A hospital implements standardized handoff communication using SBAR. This intervention primarily targets which safety risk?
- Medication reconciliation errors
- Communication failures during care transitions (Correct answer)
- Diagnostic delays
- Wrong-site surgery
Correct answer: Communication failures during care transitions
SBAR (Situation, Background, Assessment, Recommendation) provides a structured format to reduce communication failures during patient handoffs.
Question 5: Which proactive risk assessment tool assigns a Risk Priority Number (RPN) by multiplying severity, occurrence, and detectability scores?
- Root Cause Analysis
- Failure Mode and Effects Analysis (FMEA) (Correct answer)
- Tracer Methodology
- HFMEA
Correct answer: Failure Mode and Effects Analysis (FMEA)
FMEA calculates an RPN (Severity × Occurrence × Detection) to prioritize which failure modes require the most urgent mitigation.
Question 6: Which practice is a core element of the IHI's 'bundles' approach to preventing central line-associated bloodstream infections (CLABSI)?
- Weekly line site rotation
- Hand hygiene before line insertion (Correct answer)
- Antibiotic prophylaxis for all central lines
- Daily line flushing with heparin
Correct answer: Hand hygiene before line insertion
Hand hygiene before central line insertion is a fundamental element of CLABSI prevention bundles validated by the IHI.
Question 7: A wrong-site surgery occurs. According to The Joint Commission, this is classified as a:
- Serious reportable event
- Sentinel event (Correct answer)
- Near miss
- Adverse drug event
Correct answer: Sentinel event
Wrong-site surgery is defined by The Joint Commission as a sentinel event requiring thorough review and corrective action.
CPHQ Patient Safety Principles 3
Which framework specifically addresses human error in complex sociotechnical systems by categorizing failures as person-based or system-based?