Safety Flashcards
A sentinel event refers to which situation?
An event that signals the need for immediate investigation and response.
A sentinel event is an unexpected occurrence involving death or serious physical or psychologic injury or the risk thereof called sentinel, because they signal the need for
immediate investigation and response
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?
Treatment
The nurse avoided a treatment error, giving the wrong medication. Benazepril is an ace
inhibitor used to treat blood pressure. According to Leape, 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.
The strategy to avoid medication errors endorsed by the Institute for Safe Medication Practices (ISMP) to differentiate products with look-alike names is referred to as which term?
Tallman lettering
Tallman lettering is a term coined by ISMP to describe the practice of using unique letter characteristics of similar drug names known to have been confused with one another. Tallman
lettering is used to differentiate products with look-alike names such as BenaDRYL
(antihistamine) and BenaZEPRIL (ace inhibitor).
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?
Route
The right route (e.g., oral or intramuscular) is an essential component to verify prior to the
administration of any drug.
Which is an essential element of a standard order set to verify a medication order?
Metric dose/strength
The ISMP recommendations for standardized medication order sets include such elements as the drug name (generic followed by brand when appropriate), metric dose/strength, frequency
and duration, route, and indication.
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?
Fall prevention
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.
Aspects of safety culture that contribute to a culture of safety in a health care organization include which component?
Communication
Aspects that contribute to a culture of safety include leadership, teamwork, an evidence base, communication, learning, a just culture, and patient-centered care.
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?
“We’ll conduct a root cause analysis.”
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.
To promote a safety culture, 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?
Workload fluctuations
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.
