ch 45 Flashcards
A sentinel event refers to which situation?
a. An event that could have harmed a patient, but serious harm didn’t occur because
of chance
b. An event that harms a patient as a result of underlying disease or condition c. An event that harms a patient by omission or commission, not an underlying
disease or condition
d. An event that signals the need for immediate investigation and response
ANS: D
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof called sentinel, because it signals the need for immediate investigation and response. A near-miss refers to an error or commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance. Harm that relates to an underlying disease or condition provides the rationale for the close monitoring and supervision provided in a healthcare setting. An adverse event is one that results in unintended harm because of the commission or omission of an act.
The nurse is caring for a patient experiencing an allergic reaction to a bee sting who has an order for diphenhydramine (BenaDRYL). The only medication in the patient’s medication bin is labeled BenaZEPRIL. The nurse contacts the pharmacy for the correct medication to avoid what type of error?
a. Communication
b. Diagnostic
c. Preventive
d. Treatment
ANS: D
The nurse avoided a treatment error, giving the wrong medication. Benazepril is an ace inhibitor used to treat blood pressure. The Institute of Medicine (IOM) report referred to Leape’s identification of four types of errors. Treatment errors occur in the performance of an operation, procedure, or test; in administering a treatment; in the dose or method of administering a drug; or in avoidable delay in treatment or in responding to an abnormal test. Communication errors refer to those that occur from a failure to communicate. Diagnostic errors are the result of a delay in diagnosis, failure to employ indicated tests, use of outmoded tests, or failure to act on results of monitoring or testing. Preventive errors occur when there is inadequate monitoring or failure to provide prophylactic treatment or follow-up of treatment.
A nurse administers an incorrect medication to a patient. In reviewing this medication error, the nurse finds out that incorrect medication was placed in the Pyxis system. What type of error has the nurse committed?
a. Latent error
b. Blunt end
c. Did not follow nursing process
d. Latent error resulting in active error
ANS: D
The situation described is a latent error which resulted in an active error as incorrect medication was placed in the Pyxis system. Latent errors are also referred to as blunt end whereas active errors are applied as occurring at the sharp end. There is no provided information to suggest that the nurse did not follow nursing process.
Prior to drug administration the nurse reviews the seven rights, which include right patient, right medication, right time, right dose, right education, right documentation, and what other right?
a. Room
b. Route
c. Physician
d. Manufacturer
ANS: B
The right route (e.g., oral or intramuscular) is an essential component to verify prior to the administration of any drug. The patient does not need to be in a specific location. There may be a number of physicians caring for a patient who prescribe medications for any given patient. A similar drug may be made by a number of different companies, and checking the manufacturer is not considered one of the seven rights. However, the nurse will want to be aware of a difference, because different companies prepare the same medication in different ways with different inactive ingredients, which can affect patient response.
Which nursing action indicates that a nurse is more likely to incur a medication error during medication administration?
a. Checks the original medication order on the patient’s chart
b. Asks the patient to state his/her name and date of birth
c. Does not scan the barcode of the patient prior to administering the medication
d. Does not provide the patient with a glass of water
ANS: C
Use of barcode scanning of both the medication and the patient’s hospital band is critical to maintaining safe practice during medication administration. The nurse by not scanning the barcode is not maintaining the required elements and as a result is more likely to incur a medication error. Checking the original order and asking the patient to provide identification are required elements. Not providing a glass of water to the patient is not related to a medication error but does not represent best practice unless the patient is NPO except meds which would require sips of water.
To promote safety, the nurse manager sensitive to point of care (sharp end) and systems level (blunt end) exemplars works closely with staff to address which point of care exemplar?
a. Care coordination
b. Documentation
c. Electronic records
d. Fall prevention
ANS: D
The most common safety issues at the sharp end include prevention of decubitus ulcers, medication administration, fall prevention, invasive procedures, diagnostic workup, recognition of/action on adverse events, and communication. These are the most common issues the staff nurse providing direct patient care encounters. Each of the other options is classified as systems level exemplars.
Aspects of safety culture that contribute to a culture of safety in a healthcare organization include which component?
a. Communication
b. Fear of punishment
c. Malpractice implications
d. Team nursing
ANS: A
Aspects that contribute to a culture of safety include leadership, teamwork, an evidence base, communication, learning, a just culture, and patient-centered care. Fear of professional or personal punishment and concern about malpractice implications are considered barriers to a culture of safety. No model of nursing care has been related to a culture of safety.
A staff nurse reports a medication error due to failure to administer a medication at the scheduled time. What is the charge nurse’s best response?
a. “We’ll conduct a root cause analysis.”
b. “That means you’ll have to do continuing education.”
c. “Why did you let that happen?”
d. “You’ll need to tell the patient and family.”
ANS: A
In a just culture the nurse is accountable for their actions and practice, but people are not punished for flawed systems. Through a strategy such as root cause analysis the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences. Requiring continued education may be an appropriate recommendation but not until data is collected about the event. Telling the patient is part of transparency and the sharing and disclosure among stakeholders, but it is generally the role of risk management staff, not the staff nurse.
To promote a culture of safety, the nurse manager preparing the staff schedule considers the anticipated census in planning the number and experience of staff on any given shift. Which is the human factor primarily addressed with this consideration?
a. Available supplies
b. Interdisciplinary communication
c. Interruptions in work
d. Workload fluctuations
ANS: D
Including an adequate number of staff members with experience caring for anticipated patients is a strategy to manage the workload and potential fluctuations. A safety culture requires organizational leadership (e.g., the nurse manager) that gives attention to human factors such as managing workload fluctuations. This strategy also applies principles of crew resource management in that it addresses workload distribution. Lack of supplies can create a challenge for safe care but could not be addressed with the schedule. Concerns with communication and coordination across disciplines, including power gradients, and excessive professional courtesy can create hazards but would not be the best answer. Strategies to minimize interruptions in work are essential but would not be the best answer in this situation.
