KEEPING CLIENTS SAFE: ERROR AND SAFETY IN BEHAVIORAL HEALTH SETTINGS Answer Keys & Rationales 1. The correct answer is b. Rationale: From an HRO perspective, it would be a mistake to eliminate steps in a critical patient process, especially if the only objective is to save time for frontline staff members. Mistakes can certainly occur when necessary processes are overly simplified and should therefore be critically resisted and examined to determine how they affect the possibility of patient risk. 2. The correct answer is a. Rationale: From an RCA perspective, a critical element for success is the application of an RAC process to the exact context of a particular setting or practice. General RCA concepts might apply; however, specific factors will quickly need to be addressed in order for the new program to be effective. This customization allows for concepts to serve the precise needs of patients, providers, and leadership within a very specific healthcare environment. Rationale: This revelation of suicidal ideation and planning is critical. Ellen can act now to obtain authorization to speak with his wife and primary care provider, including them in creating a safer system of care for her new patient. Because the patient is new, it would be unwise to prematurely force him toward psychiatric admission—he might refuse, or potentially even more prematurely terminate with Ellen. Building rapport and creating a support team (his wife and primary care provider) establish the right clinical approach to keep her patient in therapy, which is the safest approach at this moment. KEEPING CLIENTS SAFE: ERROR AND SAFETY IN BEHAVIORAL HEALTH SETTINGS Final Examination Questions Select the best answer for each question and complete your test online at EliteLearning.com/Book 22. In 1999, the Institute of Medicine named preventable medical accidents as the: a. Leading cause of death in the U.S. 3. The correct answer is b. Rationale: From a speaking-up perspective, Janet’s best course of action is to speak up to Mark. If this is a pattern of oversight, or becomes a pattern of oversight, an adverse patient event is likely to occur. Janet is naturally anxious about speaking up to her supervisor because she is a new employee on the unit; however, she has a duty to the patients and the hospital to be responsible and work to keep all patients safe. 4. The correct answer is c.
27. 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. 28. 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. 29. 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. 30. The authority gradient affects patient safety when clinicians: a. Do not question the decisions of supervisors or leaders. b. Routinely take shortcuts to get the job done. c. Assume someone else will handle the problem. d. Engage in reckless behavior. 31. Root cause analysis is a structured process that: a. Looks to quickly identify the persons responsible for an error. b. Seeks to identify both what happened and why it happened. c. Is optional for organizations accredited by The Joint Commission. d. Is a dated process and not used by organizations investigating errors.
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. 23. 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. 24. 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. 25. An active failure is best defined as: 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. 26. 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.
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Book Code: PYFL4024
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