__________________________________ Keeping Clients Safe: Error and Safety in Behavioral Health Settings
F inal E xam
KEEPING CLIENTS SAFE: ERROR AND SAFETY IN BEHAVIORAL HEALTH SETTINGS
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5. An adverse patient event that is caused by a failure at the blunt end is defined as: A) A mistake caused at the level of the organization, residing, often hidden, within the system. B) A mistake caused by a single clinician in a single moment. C) A communication error between the clinician and the patient. D) A medication prescribing error made on an inpatient unit. 6. A just culture balances individual accountability with a system focus by: A) Honoring differences of opinion in clinical judgment and treatment protocols. B) Supporting a blame-free environment, and not tolerating blameworthy behaviors. C) Terminating the employment of clinicians who make occasional slips. D) Blaming clinicians for organizational-system-related problems. 7. Which statement is true regarding a culture of blame? A) Near misses and adverse events are taken as learning opportunities. B) Staff members are well trained on adverse event reporting. C) Clinicians are held 100% responsible for all mistakes. D) Victims of medical errors are fully informed when medical errors occur. 8. Hindsight bias causes observers of an accident to: A) Blame everyone who was in the area when the accident happened. B) Greatly exaggerate what the involved individual should have been able to foresee before the accident. C) Accept unworkable conditions as normal and to be expected. D) Attribute bad outcomes to personal inadequacies or criminal behavior.
1. In 1999, the Institute of Medicine named preventable medical accidents as the: A) Leading cause of death in the U.S. B) Eighth leading cause of death in the U.S. C) Second leading cause of death in the U.S. D) 28th leading cause of death in the U.S. 2. In an effort to improve patient safety, the human factors approach: A) Ignores negligence and individual responsibility. B) Attributes harm to insufficient layers of protection embedded in work processes. C) Rejects the notion that mistakes are inevitable and attributes adverse events to negligence. D) Searches for a single cause when an accident occurs and holds workers accountable for their mistakes. 3. The Swiss Cheese Model is a visual depiction of: A) Only the sharp end of the system, where hidden vulnerabilities reside. B) The blunt end of the system, where clinician meets patient. C) A single way to prevent accidents and promote safety. D) Different points within an organizational system at which failures can occur. A) An incident that causes no harm to the patient and requires no corrective action. B) An incident that occurs at the blunt end of the system. C) An operational error that is caused by action, inaction, or faulty decision making. D) A dormant weakness within the system that causes an error. 4. An active failure is best defined as:
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