HAC Clinical Procedures & Protocols 2 — Questions and Answers
Question 1: Which standardized protocol is used to rapidly assess and communicate a patient's deteriorating condition to a physician?
- SBAR (Correct answer)
- SOAP
- HIPAA
- PDSA
Correct answer: SBAR
SBAR (Situation, Background, Assessment, Recommendation) is the standardized communication tool used to escalate patient deterioration concerns.
Question 2: Under the National Patient Safety Goals, how frequently must a patient's identity be verified before administering medication?
- Once at admission
- Every 8 hours
- Each time medication is given (Correct answer)
- Only when a new nurse takes over care
Correct answer: Each time medication is given
The Joint Commission requires two patient identifiers to be confirmed before every medication administration event.
Question 3: What is the primary purpose of a clinical care pathway?
- To replace physician judgment in complex cases
- To standardize care and reduce unnecessary variation for a defined patient population (Correct answer)
- To document billing codes for payer submission
- To assign nursing staff based on patient acuity
Correct answer: To standardize care and reduce unnecessary variation for a defined patient population
Care pathways outline evidence-based, time-specific interventions to reduce variation and improve outcomes for a specific diagnosis or procedure.
Question 4: Which surgical safety tool requires a team briefing before incision, a pause to confirm site and procedure, and a sign-out before the patient leaves the OR?
- Time-out protocol
- WHO Surgical Safety Checklist (Correct answer)
- Pre-operative assessment form
- Informed consent document
Correct answer: WHO Surgical Safety Checklist
The WHO Surgical Safety Checklist has three phases—Sign In, Time Out, and Sign Out—to prevent wrong-site, wrong-patient, and wrong-procedure errors.
Question 5: An analyst reviewing central line insertion data notices a spike in CLABSI rates. Which bundle element is most likely deficient if the data shows lines are not being removed when no longer needed?
- Hand hygiene compliance
- Maximal barrier precautions
- Daily review of line necessity (Correct answer)
- Chlorhexidine skin antisepsis
Correct answer: Daily review of line necessity
The central line bundle includes daily review of line necessity and prompt removal when lines are no longer clinically indicated to reduce CLABSI risk.
Question 6: Which metric best measures adherence to a clinical protocol across a patient population?
- Average length of stay
- Protocol compliance rate (Correct answer)
- Cost per discharge
- Patient satisfaction score
Correct answer: Protocol compliance rate
Protocol compliance rate directly quantifies the proportion of eligible patients who received all required protocol elements.
Question 7: A hospital wants to reduce ventilator-associated events (VAE). Which intervention is a core element of the ventilator bundle?
- Prone positioning for all mechanically ventilated patients
- Daily sedation vacations and assessment of readiness to extubate (Correct answer)
- Routine bronchoscopy every 48 hours
- Administration of prophylactic antibiotics
Correct answer: Daily sedation vacations and assessment of readiness to extubate
Daily sedation interruptions paired with spontaneous breathing trials assess readiness to wean and are foundational VAE prevention bundle elements.
HAC Clinical Procedures & Protocols 2
Which standardized protocol is used to rapidly assess and communicate a patient's deteriorating condition to a physician?