CMM Patient Safety & Risk Management Flashcards

Which federal agency is responsible for setting patient safety standards and accrediting healthcare organizations in the United States?

Answer: The Joint Commission (TJC)

The Joint Commission is the primary accreditation body for US hospitals and healthcare organizations, setting patient safety and quality standards.

A 'sentinel event' in healthcare is defined as:

Answer: An unexpected occurrence resulting in death or serious physical harm

The Joint Commission defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury requiring investigation.

Root cause analysis (RCA) in patient safety is BEST described as:

Answer: A retrospective method to identify the systemic causes of an adverse event

RCA is a structured retrospective process that examines systemic and process failures rather than individual blame to prevent recurrence.

Which patient safety initiative requires hospitals to report on a set of standardized measures to CMS for public transparency?

Answer: Hospital Inpatient Quality Reporting (IQR) Program

The Hospital IQR Program requires hospitals to submit standardized quality data to CMS, which is publicly reported on Hospital Compare.

The 'Swiss Cheese Model' of accident causation in healthcare illustrates that:

Answer: Errors reach patients only when multiple system defense layers fail simultaneously

James Reason's Swiss Cheese Model shows that harm occurs when holes in multiple defensive layers (policies, training, checks) align, allowing an error to pass through.

A medical manager implementing a 'Just Culture' policy encourages staff to:

Answer: Report all errors and near-misses without fear of punitive blame for honest mistakes

Just Culture distinguishes between human error, at-risk behavior, and reckless behavior, encouraging open reporting while holding staff accountable fairly.