ISMP Patient Safety Culture 2 — Questions and Answers
Question 1: Which ISMP-promoted concept describes the process of healthcare organizations learning from each other's medication errors?
- Competitive analysis
- Shared learning through error reporting programs and safety alerts (Correct answer)
- Proprietary research only
- Individual hospital confidentiality
Correct answer: Shared learning through error reporting programs and safety alerts
ISMP promotes shared learning through national error reporting and safety alerts, allowing all organizations to benefit from errors that occurred elsewhere.
Question 2: ISMP's 'culture of safety' discourages which type of response to medication errors?
- Thorough root cause analysis
- Blaming and shaming the individual who made the error (Correct answer)
- Transparent reporting
- Systems redesign
Correct answer: Blaming and shaming the individual who made the error
Blame-and-shame responses to errors undermine safety culture by driving errors underground and preventing the organizational learning needed to prevent recurrence.
Question 3: According to ISMP, an effective error reporting system should be:
- Mandatory, punitive, and high-effort
- Voluntary, non-punitive, easy to use, and provide feedback to reporters (Correct answer)
- Accessible only to managers
- Anonymous with no follow-up
Correct answer: Voluntary, non-punitive, easy to use, and provide feedback to reporters
ISMP recommends error reporting systems that are easy to use, non-punitive, and provide feedback to reporters so that staff trust the process and participate consistently.
Question 4: ISMP's concept of 'defense in depth' for medication safety means:
- A single strong pharmacist can prevent all errors
- Layering multiple independent safeguards so that if one fails, others catch the error (Correct answer)
- Using only one safety check per drug
- Relying exclusively on technology
Correct answer: Layering multiple independent safeguards so that if one fails, others catch the error
Defense in depth layers multiple independent safeguards (e.g., prescriber alert + pharmacist review + nurse check + barcode scan) so that no single failure can cause harm.
Question 5: Which ISMP recommendation helps ensure that medication safety improvements after an error are sustained over time?
- One-time staff memos
- Monitoring and measuring outcomes after implementing safety changes (Correct answer)
- Relying on staff memory
- Annual policy reviews only
Correct answer: Monitoring and measuring outcomes after implementing safety changes
ISMP emphasizes ongoing measurement and monitoring after safety interventions to confirm that improvements are working and that errors have not recurred.
Question 6: ISMP promotes which approach when a staff member reports a medication error they were involved in?
- Immediate suspension
- Compassionate support combined with system-focused investigation (Correct answer)
- Public announcement to the hospital
- Mandatory retraining with no system review
Correct answer: Compassionate support combined with system-focused investigation
ISMP recommends supporting staff involved in errors as 'second victims' while simultaneously conducting a system-focused investigation to find and fix root causes.
ISMP Patient Safety Culture 2
Which ISMP-promoted concept describes the process of healthcare organizations learning from each other's medication errors?