RHS Quality Improvement & Patient Safety 1 — Questions and Answers
Question 1: What does the term 'sentinel event' refer to in healthcare quality improvement?
- An unexpected occurrence involving death or serious physical or psychological injury (Correct answer)
- A routine adverse drug event requiring standard documentation
- A minor incident that occurs near a patient without causing harm
- A scheduled safety audit of clinical procedures and policies
Correct answer: An unexpected occurrence involving death or serious physical or psychological injury
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, requiring immediate investigation and response.
Question 2: Which organization developed and annually updates the National Patient Safety Goals (NPSGs)?
- The Joint Commission (Correct answer)
- Centers for Medicare & Medicaid Services
- Institute for Healthcare Improvement
- Agency for Healthcare Research and Quality
Correct answer: The Joint Commission
The Joint Commission developed the National Patient Safety Goals and updates them annually to address specific areas of concern in patient safety across accredited facilities.
Question 3: A root cause analysis (RCA) in healthcare is primarily used to:
- Discipline staff members involved in patient errors
- Identify underlying system factors that contributed to an adverse event (Correct answer)
- Document all adverse events for mandatory regulatory reporting
- Calculate the financial impact of medical errors on the organization
Correct answer: Identify underlying system factors that contributed to an adverse event
RCA is a systematic process for identifying basic or contributing causal system factors behind an adverse event in order to prevent recurrence.
Question 4: The Swiss Cheese Model of accident causation in patient safety was developed by:
- James Reason (Correct answer)
- Avedis Donabedian
- Lucian Leape
- Peter Pronovost
Correct answer: James Reason
James Reason developed the Swiss Cheese Model, which illustrates how multiple layers of defense can simultaneously fail, allowing errors to reach and harm patients.
Question 5: What does PDSA stand for in the quality improvement cycle used in healthcare?
- Plan, Design, Study, Assess
- Plan, Do, Study, Act (Correct answer)
- Prepare, Develop, Sustain, Analyze
- Process, Define, Standardize, Audit
Correct answer: Plan, Do, Study, Act
PDSA (Plan, Do, Study, Act) is a four-step iterative improvement cycle used to test changes on a small scale and learn from results before broader implementation.
Question 6: Which error prevention technique requires the recipient of a verbal or telephone order to repeat it back to the prescriber?
- SBAR communication
- Read-back verification (Correct answer)
- Time-out procedure
- Bedside shift reporting
Correct answer: Read-back verification
Read-back (or repeat-back) verification requires the order recipient to verbally repeat the order to the prescriber for confirmation, reducing transcription and misinterpretation errors.
Question 7: What is the primary purpose of a 'near miss' reporting system in a healthcare organization?
- To penalize staff who make errors before they reach patients
- To identify potential hazards and system failures before they cause patient harm (Correct answer)
- To document billing discrepancies for insurance review purposes
- To track individual employee performance metrics over time
Correct answer: To identify potential hazards and system failures before they cause patient harm
Near miss reporting allows organizations to identify vulnerabilities in systems and processes proactively, enabling corrective action before an actual patient harm event occurs.
RHS Quality Improvement & Patient Safety 1
What does the term 'sentinel event' refer to in healthcare quality improvement?