CHSP Incident Investigation and Analysis Questions and Answers

Question 1

An incident investigation team is applying James Reason's "Swiss Cheese Model" of accident causation to analyze a medication error.
In this model, what do the "holes" in the slices of cheese represent?

Accepted Answer

Latent failures or weaknesses in the organization's layers of defense.

Answer

Active failures by frontline personnel.

Answer

The number of staff involved in the incident.

Answer

The financial impact of the adverse event.

Question 2

A safety officer is interviewing a nurse immediately following a patient fall. To ensure an effective and unbiased investigation that supports a Just Culture, which interview approach is MOST appropriate?

Accepted Answer

Asking open-ended, non-leading questions such as, "Can you walk me through what happened from your perspective?"

Answer

Starting the interview by asking, "Why did you let the patient fall?"

Answer

Conducting the interview with the nurse's department manager present to ensure accountability.

Answer

Focusing solely on the nurse's actions and decisions at the moment of the fall.

Question 3

Which of the following is the most significant benefit of systematically investigating and analyzing 'near miss' events in a healthcare setting?

Accepted Answer

It identifies and corrects system vulnerabilities before they cause patient harm.

Answer

It fulfills the minimum incident reporting requirements for The Joint Commission.

Answer

It provides a clear basis for disciplinary action against negligent employees.

Answer

It allows the organization to benchmark its error rates against national averages.

Question 4

According to The Joint Commission, an unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof, is known as a:

Accepted Answer

Sentinel Event

Answer

Reportable Incident

Answer

Adverse Outcome

Answer

Medical Malpractice Claim

Question 5

A root cause analysis team is investigating a wrong-site surgery. They are brainstorming all conceivable factors and grouping them into categories such as People, Process, Equipment, and Environment. Which classic analysis tool are they MOST likely using?

Accepted Answer

Fishbone (Ishikawa) Diagram

Answer

Fault Tree Analysis (FTA)

Answer

5 Whys

Answer

Failure Mode and Effects Analysis (FMEA)

Question 6

Following a root cause analysis of a retained surgical item, a corrective action plan is developed. Which of the following proposed actions is the STRONGEST and most effective?

Accepted Answer

Implementing a system where all sponges are tagged with RFID chips that are scanned before the patient leaves the OR.

Answer

Retraining all surgical staff on the proper counting procedure.

Answer

Placing posters in the operating room reminding staff of the importance of accurate counts.

Answer

Updating the policy to require a second nurse to verify all surgical counts.

An incident investigation team is applying James Reason's "Swiss Cheese Model" of accident causation to analyze a medication error.In this model, what do the "holes" in the slices of cheese represent?

An incident investigation team is applying James Reason's "Swiss Cheese Model" of accident causation to analyze a medication error.
In this model, what do the "holes" in the slices of cheese represent?