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 21. In 1999, the Institute of Medicine named preventable medical accidents as the: a. Leading cause of death in the U.S.
28. 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. 29. 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. 30. 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. 31. A high reliability organizations (HRO) is defined as: a. An organization that fails to take steps to address medical errors. b. A partner organization with The Joint Commission. c. A complex organization that engages in high-risk activities but experiences few catastrophes. d. An organization with very reliable providers. 32. Full disclosure is best defined as: a. A practice that produced malpractice lawsuits. b. The full release of a patient’s medical records to the media following a high-profile medical error. c. A plan of corrective action following a medical error. d. Full and complete communication that a provider discloses after a medical error. 33. The most frequently reported sentinel event in behavioral health settings is: a. Suicide in inpatient psychiatric units. b. Misdiagnosed psychiatric conditions. c. Medication error or mismanagement. d. The same as the most prevalent sentinel event reported in medical settings. 34. The 2014 Behavioral Health Care National Patient Safety Goal to improve assessment of suicide risk: a. Is intended for hospitalized patients only and does not involve discharge protocols. b. Is designed to increase the number of patients admitted. c. A goal was not identified for 2014. d. Involves correctly identifying high-risk suicidal patients, including during admission and after discharge. 35. Research has identified that 80% of suicide victims had: a. Contact with primary care within one year of their suicide.
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. 22. 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. 23. 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. 24. 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. 25. 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. 26. 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. 27. 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.
b. A lapse in taking their prescribed medication. c. Adequate adaptation and good social support. d. Never gone to primary care.
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Book Code: PCUS1624
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