CPHRM Patient Safety 3 — Questions and Answers
Question 1: Which of the following is an example of a high-reliability organization (HRO) principle applied to healthcare?
- Accepting variation as normal
- Preoccupation with failure and sensitivity to operations (Correct answer)
- Delegating safety decisions to frontline staff only
- Reducing incident reporting to limit liability exposure
Correct answer: Preoccupation with failure and sensitivity to operations
HROs maintain chronic unease about potential failures and stay attuned to operational conditions that could lead to harm.
Question 2: When conducting a root cause analysis (RCA) after a patient fall, which question is MOST appropriate to ask?
- Which nurse was responsible?
- What system or process conditions allowed this to happen? (Correct answer)
- How many times has this patient fallen before?
- Was the patient compliant with safety instructions?
Correct answer: What system or process conditions allowed this to happen?
RCA focuses on system-level contributing factors rather than individual blame to prevent recurrence of the event.
Question 3: A surgical team skips the pre-operative timeout due to time pressure. The GREATEST patient safety risk this creates is:
- Extended recovery time
- Wrong-site surgery or incorrect procedure (Correct answer)
- Anesthesia overdose
- Post-operative infection
Correct answer: Wrong-site surgery or incorrect procedure
The surgical timeout is the final verification step designed specifically to prevent wrong-site, wrong-procedure, and wrong-patient surgeries.
Question 4: Which safety strategy involves double-checking a high-alert medication dose independently before administration?
- Read-back verification
- Independent double-check (Correct answer)
- Tall man lettering
- Bar-code medication administration
Correct answer: Independent double-check
Independent double-checks require two clinicians to separately verify a calculation or drug without conferring, reducing the chance of shared cognitive error.
Question 5: A healthcare organization implements electronic medication reconciliation at every care transition. This intervention PRIMARILY addresses which patient safety risk?
- Duplicate diagnostic testing
- Medication discrepancies and omission errors at handoff (Correct answer)
- Surgical site infections
- Patient identification errors
Correct answer: Medication discrepancies and omission errors at handoff
Medication reconciliation ensures an accurate and complete medication list is maintained across transitions of care, preventing errors of omission or duplication.
Question 6: Under the Leapfrog Group safety standards, which hospital practice has the STRONGEST evidence for reducing ICU mortality?
- Mandatory visiting hour restrictions
- Intensivist-led ICU physician staffing (Correct answer)
- Universal private room policies
- Daily patient satisfaction surveys
Correct answer: Intensivist-led ICU physician staffing
Leapfrog standards include 24/7 intensivist coverage in ICUs, which is associated with significant reductions in mortality and complications.
Question 7: Which of the following BEST describes 'alarm fatigue' in a hospital setting?
- Staff becoming physically tired from responding to alarms
- Desensitization to alarms due to high frequency of non-actionable alerts (Correct answer)
- Patient anxiety caused by frequent monitor alarms
- Equipment malfunction due to overuse of alarm systems
Correct answer: Desensitization to alarms due to high frequency of non-actionable alerts
Alarm fatigue occurs when an excessive number of alarms causes staff to become desensitized, increasing the risk that critical alarms will be missed.
CPHRM Patient Safety 3
Which of the following is an example of a high-reliability organization (HRO) principle applied to healthcare?