Patient Safety Principles Flashcards

Which framework specifically addresses human error in complex sociotechnical systems by categorizing failures as person-based or system-based?

Answer: James Reason's Human Error Model

James Reason's model distinguishes between person-centered approaches (blame the individual) and system approaches (fix the organization).

In a hospital, nurses routinely skip the two-patient identifier check because it slows workflow. Over time staff accept this as normal. This phenomenon is called:

Answer: Normalization of deviance

Normalization of deviance occurs when unsafe workarounds become accepted as the norm because no immediate harm results.

Which element is REQUIRED for a valid informed consent process in the United States?

Answer: Disclosure of material risks, benefits, and alternatives

Valid informed consent requires disclosure of material risks, benefits, and alternatives so the patient can make a voluntary, informed decision.

A hospital implements standardized handoff communication using SBAR. This intervention primarily targets which safety risk?

Answer: Communication failures during care transitions

SBAR (Situation, Background, Assessment, Recommendation) provides a structured format to reduce communication failures during patient handoffs.

Which proactive risk assessment tool assigns a Risk Priority Number (RPN) by multiplying severity, occurrence, and detectability scores?

Answer: Failure Mode and Effects Analysis (FMEA)

FMEA calculates an RPN (Severity × Occurrence × Detection) to prioritize which failure modes require the most urgent mitigation.

Which practice is a core element of the IHI's 'bundles' approach to preventing central line-associated bloodstream infections (CLABSI)?

Answer: Hand hygiene before line insertion

Hand hygiene before central line insertion is a fundamental element of CLABSI prevention bundles validated by the IHI.

A wrong-site surgery occurs. According to The Joint Commission, this is classified as a:

Answer: Sentinel event

Wrong-site surgery is defined by The Joint Commission as a sentinel event requiring thorough review and corrective action.