CHSP Incident Investigation and Analysis Questions and Answers — 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?
- Active failures by frontline personnel.
- The number of staff involved in the incident.
- Latent failures or weaknesses in the organization's layers of defense. (Correct answer)
- The financial impact of the adverse event.
Correct answer: Latent failures or weaknesses in the organization's layers of defense.
In the Swiss Cheese Model, the slices of cheese are the organization's defenses and safeguards (e.g., policies, technologies, training). The holes represent latent conditions or hidden weaknesses within those defenses. An accident occurs when the holes in multiple defensive layers momentarily align, allowing a hazard to result in patient harm.
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?
- Starting the interview by asking, "Why did you let the patient fall?"
- Conducting the interview with the nurse's department manager present to ensure accountability.
- Focusing solely on the nurse's actions and decisions at the moment of the fall.
- Asking open-ended, non-leading questions such as, "Can you walk me through what happened from your perspective?" (Correct answer)
Correct answer: Asking open-ended, non-leading questions such as, "Can you walk me through what happened from your perspective?"
Open-ended, non-leading questions encourage a narrative account of the event without assigning premature blame. This approach is crucial for uncovering system factors and latent conditions. Asking a direct "why" question can sound accusatory, having a manager present can be intimidating and stifle open communication, and focusing only on individual actions ignores the broader system context.
Question 3: Which of the following is the most significant benefit of systematically investigating and analyzing 'near miss' events in a healthcare setting?
- It identifies and corrects system vulnerabilities before they cause patient harm. (Correct answer)
- It fulfills the minimum incident reporting requirements for The Joint Commission.
- It provides a clear basis for disciplinary action against negligent employees.
- It allows the organization to benchmark its error rates against national averages.
Correct answer: It identifies and corrects system vulnerabilities before they cause patient harm.
The primary value of near miss analysis is its proactive nature. By investigating events where harm could have occurred but didn't, an organization can identify and fix latent system problems. This prevents similar circumstances from leading to an actual adverse event in the future. It is a cornerstone of a mature safety program.
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:
- Reportable Incident
- Sentinel Event (Correct answer)
- Adverse Outcome
- Medical Malpractice Claim
Correct answer: Sentinel Event
The Joint Commission specifically defines a 'Sentinel Event' as a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are so named because they signal the need for immediate investigation and response to identify and address the root causes and prevent recurrence.
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?
- Fault Tree Analysis (FTA)
- 5 Whys
- Failure Mode and Effects Analysis (FMEA)
- Fishbone (Ishikawa) Diagram (Correct answer)
Correct answer: Fishbone (Ishikawa) Diagram
The Fishbone or Ishikawa diagram is a visual tool used to explore and categorize the potential causes of a problem. It is structured with the problem (or effect) at the 'head' of the fish, and the major categories of causes (like People, Process, Equipment) as the 'bones,' allowing the team to brainstorm and organize contributing factors.
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?
- Retraining all surgical staff on the proper counting procedure.
- Placing posters in the operating room reminding staff of the importance of accurate counts.
- Implementing a system where all sponges are tagged with RFID chips that are scanned before the patient leaves the OR. (Correct answer)
- Updating the policy to require a second nurse to verify all surgical counts.
Correct answer: Implementing a system where all sponges are tagged with RFID chips that are scanned before the patient leaves the OR.
This action represents an engineering control, which is high on the hierarchy of controls because it redesigns the system to make failure much more difficult, relying less on human memory and diligence. Retraining (A) and policy updates (D) are less effective administrative controls, and posters (B) are the weakest form of intervention (awareness).
CHSP Incident Investigation and Analysis Questions and Answers
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?