Risk Management & Patient Safety

Question 1

In 1999 the Institute of Medicine released what book talking about medical errors

Answer 1

To Err is Human

Question 2

Most errors are blamed on who?

Answer 2

Not one person, faulty process

Question 3

What is the AHRQ

Answer 3

Agency for Healthcare Research and Quality

Houses the national guideline clearinghouse

Question 4

What is ASHRM?

Answer 4

American Society for Healthcare Risk Management?

-early roots in OH

Question 5

What is HEN and what is its purpose?

Answer 5

Hospital Engagement Network

-shared data and implement improvement strategies

Question 6

What is IHI

Answer 6

Institute for Healthcare Improvement

• non profit
• voluntary initiatives to improve pt safety

Question 7

Current goals of ASHRM & HEN programs:

Answer 7

Decrease Inpt errors/ harm by 40%

Decrease readmission by 20%

Question 8

Most common source of error seen in

Answer 8

Medications

Question 9

Top 5 Medication ADR requiring hospitalization:

Answer 9

Insulin
Anticoagulants
Amoxicillin
Aspirin
Bactrim
-40% were unintentional overdoses

Question 10

Common errors in insulin

Answer 10

improper monitoring
Look alike packages
Abbreviations

Question 11

Common errors in anticoagulants

Answer 11

Inadequate monitoring

drug drug internxs

Question 12

Common errors in narcotics

Answer 12

Drug drug internx & sedation
Respiratory depression
multiple formulations
mg vs ml

Question 13

What drug accounts for 40% of acute liver failure causes

Answer 13

acetaminophen

Question 14

Major cause of CAUTI

Answer 14

indwelling catheters

Question 15

A tunneled central line is usually placed

Answer 15

passed under skin, usually chest

Question 16

What sites should be avoided for central line placement?

Answer 16

Femoral

Question 17

Most falls are which of the following:
Anticipated
Unanticipated
Accidental

Answer 17

Anticipated 78%

Question 18

Is bed rest appropriate for a pt on falls cautions?

Answer 18

NO

accelerates bones loss, immobility, etc

Question 19

Common sites of pressure ulcers:

Answer 19

heels/ankles
knees
hips
spine/tailbone
elbows
shoulder blades
ears/back of head

Question 20

Surgical infections lead to

Answer 20

more likely admitted to ICU
5x more likely to readmitted
2x mortality rate

Question 21

What is the mot common preventable cause of hospital death?

Answer 21

venous thromboembolism

Question 22

What is ABCDE bundle and what is it used to reduce?

Answer 22

Use to reduce ventilator associated pneumonia
Awakening & Breathing trial Coordination
Delirium assessment
Early Progressive Mobility