CPHRM Patient Safety 4 — Questions and Answers
Question 1: A patient receives a blood transfusion intended for another patient. This event should FIRST be reported as a:
- Employee incident
- Near miss
- Sentinel event (Correct answer)
- Adverse drug event
Correct answer: Sentinel event
Transfusion errors resulting in hemolytic reactions are classified as sentinel events requiring immediate investigation and reporting.
Question 2: Which of the following is the MOST effective strategy to prevent central line-associated bloodstream infections (CLABSIs)?
- Routine prophylactic antibiotics
- Implementing a central line insertion bundle with checklist compliance (Correct answer)
- Replacing central lines every 72 hours
- Using heparin flushes after each access
Correct answer: Implementing a central line insertion bundle with checklist compliance
Evidence-based insertion bundles—including hand hygiene, maximal barrier precautions, and chlorhexidine skin antisepsis—significantly reduce CLABSI rates.
Question 3: A patient with limited English proficiency receives discharge instructions only in English. This situation MOST directly creates a risk for:
- HIPAA violation
- Post-discharge medication errors and non-compliance (Correct answer)
- Fraudulent billing
- Delayed hospital reimbursement
Correct answer: Post-discharge medication errors and non-compliance
Health literacy barriers increase the risk of misunderstood instructions, leading to medication errors, readmissions, and poor health outcomes.
Question 4: Which of the following is a key component of a comprehensive fall prevention program in an acute care hospital?
- Restricting patient ambulation
- Individualized fall risk assessment with targeted interventions (Correct answer)
- Placing all patients on bed rest
- Requiring patients to sign fall waiver forms
Correct answer: Individualized fall risk assessment with targeted interventions
Individualized risk stratification using validated tools (e.g., Morse Fall Scale) followed by matched interventions is the evidence-based standard for fall prevention.
Question 5: The concept of 'defense in depth' in patient safety refers to:
- Training staff to defend against patient complaints
- Layering multiple independent safeguards so that one failure alone does not cause harm (Correct answer)
- Reviewing incident reports in depth
- Creating strict penalties for repeated errors
Correct answer: Layering multiple independent safeguards so that one failure alone does not cause harm
Defense in depth applies redundant safety barriers so that if one layer fails, others remain to catch the error before it reaches the patient.
Question 6: During a hospital survey, a surveyor asks staff to describe what they would do if they noticed a safety concern. This line of questioning MOST directly assesses:
- Staffing adequacy
- Safety culture and staff empowerment to speak up (Correct answer)
- Compliance with billing codes
- Equipment maintenance schedules
Correct answer: Safety culture and staff empowerment to speak up
Surveyors assess whether staff feel empowered and safe to report concerns without retaliation, which is a core indicator of patient safety culture.
Question 7: Which federal agency operates the Patient Safety Organization (PSO) program under the Patient Safety and Quality Improvement Act?
- Centers for Medicare & Medicaid Services (CMS)
- Agency for Healthcare Research and Quality (AHRQ) (Correct answer)
- Food and Drug Administration (FDA)
- Centers for Disease Control and Prevention (CDC)
Correct answer: Agency for Healthcare Research and Quality (AHRQ)
AHRQ oversees the PSO program, which provides legal protection for patient safety data reported to certified PSOs to encourage voluntary reporting.
CPHRM Patient Safety 4
A patient receives a blood transfusion intended for another patient.
This event should FIRST be reported as a: