Making Health Care Safer: A Critical Analysis of Patient Safety Practices

Self-Study Examination

Instructions: After studying the text answer the following true/false or multiple choice questions.  Remember, there's only one answer to each question.

1. The goal of critical incident monitoring is not to gather epidemiological data but to:

a) gather quantitative data
b) gather qualitative data
c) reduce critical incidents
d) prevent injury

2. When an error does not result in an adverse event for a patient because the error was “caught” it is:

a) an adverse event
b) a no-harm event
c) a near-miss event
d) an error event

3. The incident reporting system seems to capture a distinct set of events. Events captured in this manner are:

a) more preventable
b) less preventable
c) less reliable than chart review and risk management
d) anonymous and voluntary

4. In 1997, the Joint Commission on Accreditation of Healthcare Organizations mandated the use of RCA to:

a) clarify the cause of a sentinel event
b) predict the occurrence of an incident
c) improve staffing issues
d) investigate sentinel events in accredited hospitals

5. A few hospitals that have studied incident rates of adverse drug events have documented rates from:

a) 2 to 7 per 100 admissions
b) 1 to 5 per admissions
c) 10 to 15 per 100 admissions
d) 2 to 7 per 100 admissions

6. An ADE not associated with a medication error and considered non-preventable would be:

a) development of a rash after administration of ampicillin to a penicillin-llergic patient
b) administering medication by the wrong route
c) an order that is intercepted and corrected by the nurse before reaching the patient
d) medication side effects

7. All of the following describe corollary orders except:

a) checking serum creatinine 2 times a week for patients on amphotericin
b) tests for fecal occult blood in patients on heparin
c) checking the wbc’s when on antibiotics
d) audiometry for patients on vancomycin

8. The drug class most commonly associated with preventable adverse drug events was:

a) sedatives
b) analgesics
c) antibiotics
d) hypnotics

9. Examples of signals from a computerized adverse drug event monitor would be all of the following except:

a) medication stop orders
b) prediction of outcome
c) antidote ordering
d) abnormal laboratory orders

10. Inpatients that suffer adverse drug events have:

a) a sentinel event
b) an increased stay of 4 days and added hospital costs of $4,000 dollars
c) resulted in many hospitals to have integrated laboratory and medication systems
d) an increased stay of 2 days and added hospital costs of $2,000 dollars

11. All of the following are considered “high risk” medications except:

a) oral opiate analgesics
b) concentrated electrolyte solutions such as potassium chloride
c) intravenous insulin
d) heparin and warfarin

12. Heparin nomograms are primarily intended to achieve which of the following laboratory values within the therapeutic range as quickly as possible?

a) pt
b) fibrinogen levels
c) ptt
d) INR

13. Unit-dose dispensing of medication was developed to support nurses in medication administration and to:

a) make billing insurance companies easier
b) reduce the waste of expensive medication
c) keep medications organized
d) allow pharmacists more control of buying in bulk

14. Unit-dosing shifts the effort and distribution of medication processing from the nursing ward to:

a) the physician
b) a clinical pharmacist
c) the purchasing department
d) central pharmacy

15. The McLaughlin dispensing system includes all of the following except:

a) a calibrated canister
b) a bedside dispenser
c) a programmable magnetic card
d) a pharmacy computer

16. A common complaint by nurses regarding the Pyxis Medstations is:

a) only certain medications fit in the compartmentalized cabinet
b) canisters can be easily mixed up
c) long waiting lines if there are not enough machines
d) data storage is limited

17. Any action where an antiseptic solution is used to clean the hands is defined as:

a) waterless disinfection
b) standard handwashing
c) a hygienic rub
d) hand disinfection

18. Nosocomial infections occur in what percent of hospitalized patients?

a) 1-5 %
b) 7-10%
c) 3-6 %
d) 12-20%

19. One reason for poor compliance with handwashing may be that:

a) it is too time consuming
b) wearing gloves does not require handwashing
c) its importance is underestimated
d) skin irritation occurs

20. Current recommendation for standard handwashing is:

a) 15-30 seconds for adequate hand hygiene
b) 30-45 seconds for adequate hand hygiene
c) the length of time it takes to sing “Happy Birthday to You”
d) one minute of vigorous scrubbing

21. Each nosocomial infection costs approximately:

a) $2,500 dollars per episode
b) it varies from patient to patient
c) $10,000 dollars per episode
d) $5,000 dollars per episode

22. All of the following are true about c-difficile except:

a) the acquisition rate is 13 percent for patients hospitalized 1-2 weeks
b) a fivefold increase in clinical infection between 1993 and 1996
c) costs associated with c-difficile may be as high as $20,000 dollars per patient
d) the acquisition rate of 50 percent for patients hospitalized longer than 4 weeks

23. A potentially harmful consequence of barrier precaution interventions is:

a) families are less likely to visit patients on contact isolation
b) the psychological effect that contact precautions have on the isolated patient
c) compliance of gowning and gloving is sporadic among nurses
d) nurses are less likely to complete tasks when interventions become complicated

24. The estimated cost associated with c-difficile in the hospitalized patient may be as high as:

a) $20,000 dollars per patient
b) less than $10,000 dollars per patient
c) varies with each patient
d) $10,000 per patient

25. The most common nosocomial infection is:

a) s.aureus
b) VRE
c) c- difficile
d) VSE

26. Urinary tract infections account for what percent of nosocomial infections?

a) less than 25 percent
b) less than 10 percent
c) 40 percent
d) 75 percent

27. Multiple studies have suggested that silicone urethral catheters coated with hydrogel and silver salts reduce the risk of developing bacteriuria.

a) True
b) False

28. Catheter colonization is defined as:

a) purulent drainage at the insertion site
b) growth of an organism from the tip of a subcutaneous segment of a removed catheter
c) a positive blood culture
d) growth greater than 10 colony-forming units using the roll-plate culture technique

29. The most common organisms causing catheter-related infections are all of the following except:

a) pseudomonas
b) staphylococci
c) gram negative rods
d) candida

30. Maximum sterile barrier precautions reduce the incidence of catheter contamination during insertion and consist of all of the following except:

a) sterile gloves and long-sleeved gown
b) full-size drape
c) a sterile mask
d) non-sterile mask and cap

31. The most commonly used agent to cleanse the skin prior to insertion of a central venous catheter in the United States is:

a) chlorhexidine gluconate
b) isopropyl alcohol
c) antibacterial soap
d) povidone iodine

32. Ventilator-associated pneumonia is defined by all of the following except:

a) a temperature <36 degrees C
b) a new and persistent infiltrate on a chest x-ray
c) purulent tracheal secretions
d) leukocytes >12,000 mm3 or < 4,000 mm3

33. Continuous oscillation in randomized trials suggests that conscious patients:

a) requested more frequent sedation
b) tolerated the procedure well
c) had less benefits than unconscious patients
d) tolerated the procedure poorly

34. The goal of selective digestive tract decontamination is to:

a) neutralize the ph of stomach acid
b) destroy the normal flora of the GI tract
c) decrease the pathogenicity of aspirated secretions
d) stop peristaltic action

35. 'At an Institute of Medicine workshop, which of the following pitfalls of localizing care to high-volume settings are correct?
  1. high-volume centers have price inflation
  2. high-volume centers use data to misrepresent their experience
  3. procedures may be done that are not appropriate
  4. patients are forced to travel long distances to receive care

a) 1 and 3
b) all but 2
c) 2 and 4
d) all are correct

36. Complications from minimal access procedures fall into two general categories which are:

a) an increase in post-operative infections and gastric injury
b) lack of specific training of the surgeon and poor health of the patient
c) those directly relating from laproscopic intervention and those associated with the operation itself
d) problems with the operation itself and minimal post-op care

37. What percent of injuries were predicted to occur during the surgeon’s first 30 laparoscopic cholecystectomies?

a) 0.35
b) 0.9
c) 0.7
d) 0.1

38. Surgical site infections include all of the following except:

a) superficial incisional infections
b) infections of the deep incision space
c) organ space infections
d) intra-abdominal infections

39. Antimicrobial prophylaxis is best described as:

a) an antimicrobial given orally after surgery
b) an antimicrobial agent given prior to surgery
c) an antimicrobial instilled in the incision prior to surgery
d) an antimicrobial given IV at the time the skin is incised

40. Intraoperative hypothermia causes all of the following except:

a) increases vasodilation to the surgical site
b) impairs the immune function
c) decreases tissue oxygenation to the surgical site
d) reduces platelet function

41. Complications associated with central vein catheterization after catheter placement are all of the following except:

a) infection
b) thrombosis
c) arterial-venous fistula
d) catheter knotting

42. The greatest benefit of ultrasound guidance:

a) is a decrease in cost
b) may apply to the novice or inexperienced operator
c) is a decrease in infections
d) results in fewer mechanical complications

43. The number of sponge, sharp, and instrument counts are recommended to be:

a) 4 separate counts
b) 3 separate counts
c) 2 separate counts
d) variable with each surgery

44. According to Kaiser et al., fifty-five percent of retained sponges were found after which type of surgery?

a) thoracic
b) vaginal
c) abdominal
d) rectal

45. A “check out” list provides practitioners with a standardized approach which includes:

a) 10 processes to check between each case
b) 9 processes as an initial check out at the beginning of the day
c) variables, depending on the equipment used
d) 24 processes as an initial check out at the beginning of the day

46. The reason a single, effective, broadly generalized checklist would be difficult if not impossible is:

a) frequency of equipment failure is low
b) a duplication of work is already performed
c) variation of anesthesia delivery devices
d) check lists are viewed as low-yield and redundant

47. An example of an invasive monitor for intraoperative use would be:

a) an oxygen saturation device
b) a blood pressure cuff
c) an ECG machine
d) a transesophageal echocardiography monitor

48. Capnography is best defined as

a) oxygen monitoring
b) carbon dioxide monitoring
c) myocardial ischemia monitoring
d) respiratory monitoring

49. The most common medical complication of surgery is:

a) myocardial cardiac events
b) infection
c) evisceration
d) pain

50. Use of beta-blockade has beneficial effects in elderly patients in all of the following except:

a) they are extubated more quickly
b) they required less pain medication
c) they had a decreased number of infections
d) they are alert sooner after surgery

51. The strongest predictor of future falls is:

a) gait and balance impairment
b) environmental hazards
c) medications
d) having previously fallen

52. Problems with external hip protectors include all of the following except:

a) cost of the device
b) skin irritation and breakdown
c) noncompliance over the long term
d) discomfort wearing the device

53. What are the two tools widely used to identify at risk patients for skin breakdown?

a) Minimum Data Set and Skin Assessment Scale
b) Pressure Ulcer Assessment Scale and the Norton Scale
c) Norton Scale and Braden Scale
d) Braden Scale and the Resident Assessment Instrument

54. The passage of the Omnibus Budget Reconciliation Act of 1987 provides for all of the following except:

a) a regular skin assessment
b) weekly evaluations of pressure ulcer treatment
c) implementation of preventative measures for breakdown
d) treatment of pressure ulcers

55. The cost of treating a pressure ulcer ranges from:

a) $2,000 - $20,000
b) $10,000 - $50,000
c) $1,000 - $10,000
d) $4,000 - $40,000

56. Delirium is best defined as:

a) the result of sleep deprivation
b) an acute confusional state
c) a cognitive impairment
d) a chronic confusional state

57. General strategies to prevent delirium include all of the following except:

a) use of night lights
b) reorientation techniques
c) visible clocks and calendars
d) scheduled patient mobility

58. A consultation team consists of:

a) a nurse and rehabilitative experts
b) a psychologist, rehabilitative experts, and a dietician
c) a psychiatrist, nurse, pharmacist, and therapist
d) a physician, nurse practitioner, rehabilitative experts, and a social worker

59. In a geriatric evaluation and management unit a multidisciplinary team does all of the following except:

a) provides a comprehensive geriatric assessment
b) develops a detailed treatment plan
c) makes recommendations for placement after discharge
d) gives attention to rehabilitative needs

60. GEM units are typically:

a) free-standing units for acute geriatric patients
b) separate hospital wards that are redesigned to treat geriatric patients
c) medicare wings of a long-term care facility
d) similar to a rehabilitative unit

61. A venous thromboembolism:

a) is often clinically silent
b) has obvious symptoms, such as shortness of breath
c) has a low mortality and morbidity
d) occurs in <10 percent of patients after prophylaxis

62. The “gold standard” for diagnosis of DVT is

a) pulmonary angiography
b) contrast venography
c) x-rays
d) a Doppler study

63. Major risk factors for radiocontrast–induced nephropathy include:
  1. chronic renal insufficiency
  2. diabetes mellitus
  3. decreased effective circulation volume
  4. large doses of contrast media

a) all the above
b) 1, 2, and 3
c) all but 4
d) 4 only

64. According to early studies, what percent of hospitalized patients are malnourished?

a) 60 – 75 %
b) 10 – 20 %
c) 5 – 10 %
d) 30 – 50 %

65. TPN has been associated with an increase in:

a) aspiration pneumonia
b) mortality
c) septic complications
d) muscle depletion

66. The risk of stress ulceration and subsequent GI bleeding depends on all of the following except:

a) underlying illness
b) overuse of aspirin prior to admission
c) severity of illness
d) related comorbidities

67. A teleradiology link:
  1. must have a full-time on-site board-certified radiologist
  2. has a high image quality
  3. allows rural physicians to obtain remote consults
  4. requires use of digitalized rather than film-based x-rays
    5. <

a) 3 and 4
b) all but 2
c) 4 only
d) all the above

68. Which of the following patients are deemed to be high-risks for pneumonia?

a) traumatic injury at any age
b) a pediatric patient with leukemia
c) a patient who has had pneumonia in the previous 5 years
d) patients older than 65 years of age with certain chronic illnesses

69. The most effective delivery method of vaccination for inpatient settings is:

a) assessment on admission
b) review of previous records
c) standing orders
d) review of past illnesses

70. Acute pain services have created a framework in which:

a) patients, nurses and physicians are educated
b) appropriate analgesics are selected
c) postoperative pain can be managed more effectively
d) chronic pain problems are addressed

71. The more common side effects of patient controlled analgesia with opioids are:

a) nausea and vomiting
b) oversedation and lethargy
c) nightmares and dry mouth
d) diarrhea and bloating

72. In a closed ICU model:

a) patients are cared for by an internist or surgeon
b) intensivists play a de facto role
c) patients are cared for by a full-time intensivist
d) the mortality rate is between 12 and 17 percent

73. A large part of a nurse’s job is:

a) assessment
b) planning
c) implementation
d) evaluation

74. According to hospital–level data, increasing the percentage of RNs in the skill mix:

a) does not affect mortality
b) has decreased falls and medication errors
c) is associated with decreased risk–adjusted mortality
d) will result in a significant shortage of RNs in the United States

75. Organizations with exemplary tract records of safety are:

a) Normal Accident Theory
b) High Reliability Organization
c) Safety Outcomes Research Lab
d) Veterans Health Administration

76. Management systems, safety systems, and individual attitudes and perceptions are sometimes referred to as:

a) corporate safety
b) a safety culture
c) the safety climate
d) a culture of perfection

77. The study of how humans interact with machines and complex systems is all of the following except:

a) design factor ratio
b) human factors engineering
c) usability engineering
d) ergonomics

78. Experiments suggest that humans have difficulty reliably recognizing:

a) visual and auditory alarms simultaneously
b) more than 6 alarms at one time
c) low-frequency acoustical properties
d) three different visual interfaces

79. The process of information transfer, known as “sign-out” is often:

a) done by nurses
b) is approved by JCAHO
c) concise and consistent
d) informal and unstructured

80. The most common reason reported by physicians for not notifying patients of abnormal results was:

a) forgetfulness and inability to reach patients
b) lack of adequate staff
c) slow response in obtaining results
d) poor tracking systems

81. The oldest and most common machine-readable ID system is:

a) magnetic stripes
b) barcodes
c) optical character recognition
d) radiofrequency labeling

82. Common factors identified in wrong-site surgery include:
  1. multiple surgeries
  2. multiple procedures
  3. time constraints
  4. unusual anatomy, deformities or morbid obesity

a) all the above
b) all but 3
c) 1 and 2
d) 1 only

83. The three primary components of effective crew management are:

a) teamwork, equipment, and safety
b) education, skill, and performance
c) safety, efficiency, and morale
d) action, understanding, and motivation

84. The MedTeams behavior–based teamwork system is all of the following except:

a) developed by Dynamics Research Corporation
b) adapts research in team performance and training from military helicopter aviation to emergency medicine
c) is implemented through courses and assessment tools
d) is sponsored by the Air Force Research Lab

85. One advantage of simulation is:

a) errors can be allowed to occur and reach their conclusion
b) patient outcomes improve with repeated use
c) follow-up is concise and conclusive
d) it replicates reality

86. A potential risk to simulation–based training is:

a) it does not evaluate proficiency
b) major errors occur in management
c) a false sense of security could theoretically lead to harm
d) many simulators have not been efficient in improving performance

87. Sleep debt is defined as:

a) getting less than 5 hrs of sleep over a 24–hour period
b) getting 2 to 3 hours less sleep than optimal
c) working 36 hours at a time
d) working 80 hours a week

88. Which shift rotation would lead to less fatigue?

a) morning, evening, night shift
b) evening, night, day shift
c) night, morning, evening shift
d) evening, day, night shift

89. Sleep inertia is all of the following except:

a) confusion after awakening
b) impaired cognitive performance after awakening
c) is transitory with hypo–vigilance
d) lasts up to 60 minutes after awakening

90. All of the following are true about interhospital transport except:

a) involves transportation between hospitals
b) can be by ground or air ambulance
c) it refers to transportation within the hospital
d) may involve nurses, respiratory therapists or a specialized transport team

91. Informed consent is initiated by the:

a) nurse
b) physician
c) clinician
d) physician assistant

92. According to Hopper et al., general hospital forms are written at a grade level of:

a) 12.35 years
b) 9 years
c) 12.6 years
d) 10 years

93. A durable power of attorney for health care can be best defined as:

a) allows an individual to appoint a person to make healthcare decisions should they lose decision-making capacity
b) a document that allows an individual to indicate interventions if terminally ill
c) any expression by a patient intended to guide their care should they lose their medical decision-making capacity
d) a document that directs care according to the Natural Deaths Act

94. Even when advance directives are prepared, often they do not change interventions at the end of life for all the following reasons except:

a) admitting clerks fail to document or incorrectly document the status on admission
b) failure to bring the document to the hospital
c) advance directives are frequently not available, recognized, or applied
d) the patient is not properly identified with an identification bracelet

95. The Agency for Healthcare Research and Quality produces a 5–page “Patient Fact Sheet” regarding:

a) how to choose a physician
b) number of nosocomial infections per 100 patients
c) medical errors
d) products and services available

96. Practice guidelines are the most widely employed method of:

a) correcting nursing behavior
b) modifying physician behavior
c) regulating the number of admissions and discharges
d) reducing medical errors

97. A critical pathway is best defined as:

a) an administrative model that streamlines work and production processes
b) a document used to prevent medical errors
c) a study using statistics from other hospitals in the region
d) a method of decreasing hospital stays

98. A clinical decision support system is best defined as :

a) a support system that assists the nurse on evaluation of care
b) a 10-point scale that rates quality of outcomes
c) a structured search of bibliographies and research
d) a method of applying new information to patient care through an analysis of patient–specific clinical variables

99. All of the following are techniques used to modify behavior of practicing physicians except:

a) continuing medical education
b) opinions of leaders on a state level
c) practice guidelines
d) critical pathways

100. The survey results from JCAHO inspections are used for all of the following reasons except:

a) obtain approval for Federal regulations
b) obtain Medicare certification and state licensure
c) obtain bond ratings
d) obtain managed care contracts