DHA Patient Safety Guidelines 5 — Questions and Answers
Question 1: When using the SBAR communication tool, what does the 'R' stand for?
- Report
- Recommendation (Correct answer)
- Reassessment
- Response
Correct answer: Recommendation
In SBAR, 'R' stands for Recommendation, where the communicator suggests what action should be taken to address the patient's situation.
Question 2: A patient with a known penicillin allergy is inadvertently prescribed amoxicillin. Which system-level safeguard should have caught this error?
- Nursing bedside check
- Clinical decision support alert in the electronic health record (Correct answer)
- Pharmacist verbal counseling
- Patient self-reporting during admission
Correct answer: Clinical decision support alert in the electronic health record
Clinical decision support systems embedded in EHRs are designed to flag drug allergy conflicts at the point of prescribing before orders are processed.
Question 3: According to patient safety principles, which situation represents a 'latent condition' contributing to errors?
- A nurse who forgets to check a patient's allergy band
- Insufficient staffing ratios established by hospital administration (Correct answer)
- A physician who misreads a lab result
- A patient who does not disclose their full medication history
Correct answer: Insufficient staffing ratios established by hospital administration
Latent conditions are systemic, organizational factors such as understaffing that create environments where errors are more likely to occur.
Question 4: Under the DHA Patient Rights Framework, a patient has the right to refuse treatment. If a competent adult refuses a life-saving blood transfusion, the healthcare team should:
- Proceed with the transfusion to prevent death
- Obtain a court order to override the refusal
- Respect the refusal, document it, and ensure the patient understands the consequences (Correct answer)
- Seek consent from the next of kin to override the patient
Correct answer: Respect the refusal, document it, and ensure the patient understands the consequences
A competent adult patient has the legal and ethical right to refuse treatment; the team must document the refusal, ensure informed understanding, and respect the decision.
Question 5: Which of the following is the most appropriate action when a healthcare worker sustains a needlestick injury from a known HIV-positive patient?
- Report to occupational health immediately and initiate post-exposure prophylaxis within 72 hours (Correct answer)
- Wait for HIV test results before taking any action
- Wash the wound and continue working without reporting
- Report the incident at the end of the shift
Correct answer: Report to occupational health immediately and initiate post-exposure prophylaxis within 72 hours
Post-exposure prophylaxis must be initiated as soon as possible, ideally within 2 hours and no later than 72 hours, following immediate reporting to occupational health.
Question 6: A patient is found unresponsive in the bathroom. Which principle of patient safety best explains why bed rails and call bells should have been within reach?
- Redundancy
- Standardization
- Risk anticipation and fall prevention (Correct answer)
- Error reporting
Correct answer: Risk anticipation and fall prevention
Risk anticipation involves proactively identifying environmental hazards and implementing preventive measures such as accessible call bells to reduce patient falls.
Question 7: Which element is essential for a Root Cause Analysis (RCA) to be effective after a sentinel event?
- Identifying and disciplining the individual responsible
- Focusing exclusively on the technical failure that caused the event
- Examining the entire system, including human factors and processes (Correct answer)
- Completing the RCA within 24 hours of the event
Correct answer: Examining the entire system, including human factors and processes
An effective RCA examines all contributing system factors, human factors, and processes rather than focusing on individual blame, to develop meaningful corrective actions.
DHA Patient Safety Guidelines 5
When using the SBAR communication tool, what does the 'R' stand for?