4. 181. A nurse administers too much of a sedative because he misinterprets an order, but the
patient doesn’t feel different. Would the IHI Global Trigger Tool recognize the case as harm?
Harm
No Harm
Answer : NO harm
Explanation: The error didn’t lead to physical injury that required additional care, so this definition
would not classify it as harm. Nevertheless, the nurse should report this event so that the system can
improve. Although the error didn’t cause harm in this instance, it may contribute to harm in the future.
182. A surgeon mistakenly operates on the wrong foot, and the patient has to undergo a second
surgery. Would the IHI Global Trigger Tool recognize the case as harm?
Harm
No Harm
Answer : harm
Explanation : This event would be an example of harm because it caused a physical injury that
required more care (the second surgery).
183. A doctor tells a patient that she is HIV-positive because of a false lab result, but corrects the
mistake before there is any impact to her care.
Would the IHI Global Trigger Tool recognize the case as harm?
Harm
No Harm
Answer : NO harm
Explanation: While the patient might certainly consider this harm, it would not count as harm
under the IHI Global Trigger Tool definition. The suffering is psychological rather than
physical.
184. A patient’s test result shows she may have a blood clot, but the primary care clinic doesn’t
order the next test to confirm. In the meantime, the blood clot causes the patient to have a stroke.
Would the IHI Global Trigger Tool recognize the case as harm?
Harm
No Harm
Answer : NO harm
Explanation: The IHI Global Trigger Tool definition only includes harms caused by active
medical care (also known as errors of commission), not the absence of care, as in this scenario.
This definition also excludes diagnostic error (when providers reach the wrong diagnosis).
6. 185. Which of the following is included in the IHI Global Trigger Tool definition of harm?
A.Financial harm from expensive medical bills
B.Psychological harm such as a miscommunication about a diagnosis
C.Physical injury caused by medical care that triggers additional care
D.The absence of needed care that contributes to harm, such as missed treatment for
hypertension that leads to a stroke
Answer :C
Explanation :
Some patient safety leaders want to expand the definition of harm and include the other
types of harm listed in this question, including financial harm, psychological harm, and
so-called errors of omission, but those are not included in the IHI Global Trigger Tool
definition of harm.
7. 186. Why do some patient safety leaders believe the definition of harm should be broader than
the definition in the IHI Global Trigger Tool?
A.Because health care systems have eliminated all harms included in the current definition
B.Because health care systems should work to prevent more types of harm than the current
definition includes
C.Because expanding the definition of harm would make it easier to measure
D.Because health care providers aren’t usually concerned about harms such as psychological
injury
Answer : B
Explanation: Leaders in the field of patient safety argue that health systems should be
more expansive in their definition of harm because the definition affects the scope of
improvement work. They believe that health systems can and should prevent more types
of harm than the definition includes.
9. Dhruv, a 65-year-old retiree, is brought to the hospital after developing chest pain while gardening. He is
quickly diagnosed with an acute myocardial infarction (heart attack). However, he waits almost two
hours to get to the catheterization lab and have his blocked coronary artery opened. Ultimately, he
suffers permanent damage to his heart.
Answer : D
Explanation : Dhruv’s care was not timely. He did not receive care when it was needed, without
delays.
187.I. Which of the IOM aims has this hospital FAILED to meet?
A.Safe
B.Effective
C.Efficient
D.Timely
187.II. The hospital where Dhruv is recovering reviews its patient satisfaction survey results in order to
improve its care and patient outcomes. Leaders poring over the data note that 90 to 100 percent of
patients rate staff as “excellent” in the following categories: listening, answering questions, being friendly
and courteous, and giving good advice based on specific needs and preferences.
Which aim is the hospital generally achieving?
A.Effective
B.Efficient
C.Timely
D.Patient-Centered
Answer : D
Explanation :Patient-centered care is defined by the IOM as “care that is respectful of and responsive to
individual patient preferences, needs, and values” and that ensures “patient values guide all clinical
decisions.” These high satisfaction rates are consistent with being patient-centered.
10. 188. Regarding the Institute of Medicine’s (IOM’s) six aims for health care, which of the
following is true?
A.They represent the dominant framework for thinking about improving health care quality in
the United States and in many other countries.
B.They were first publicized in 2001, in the report Crossing the Quality Chasm: Health Care in
the 21st Century.
C.They help health care organizations have a better idea of what they need to improve.
D.All of the above
Answer : D
Explanation :The best answer is “all of the above.” In 2001, the IOM released
Crossing the Quality Chasm: Health Care in the 21st Century, which identified six key
dimensions of the US health care system and set aims for each dimension, so that
organizations would know where to focus their improvement efforts. These six aims
are so comprehensive that today they’re still the dominant framework for thinking
about improving health care quality in the US and in many other countries, as well.
11. Michael S., a 49-year-old factory worker, goes to the hospital after developing chest pain at
work. Physicians quickly diagnose him with an acute myocardial infarction (heart attack), and
he has successful surgery to open his blocked coronary artery. While he is recovering in the
hospital, he contracts an infection that could have been prevented through better infection
control practices in the hospital.
Answer : D
Explanation : The best answer is that Michael’s care was timely. Timely care means reducing
waits and sometimes harmful delays for both those who receive and those who give care. Thanks
to the fast surgery Michael received, he avoided permanent damage to his heart.
189.I. Which of the IOM aims has this hospital most clearly met?
A.Patient-Centered
B.Equitable
C.Safe
D.Timely
189.II. Which of the IOM aims has this hospital failed to meet?
A.Effective
B.Safe
C.Equitable
D.Timely
Answer : B
Explanation :The best answer is “safe.” Safe care means avoiding injuries to patients from
the care that is intended to help them. Michael contracted an infection because his care was
not as safe as it could have been.
12. 190. Which of the following improvement efforts is the best example of increasing the equity
of care?
A.Decreasing adverse drug events by having a pharmacist on rounds in the intensive care
unit
B.Shortening wait times at a clinic by allowing patients to self-register on a computer in the
waiting room
C.Instituting quarterly focus groups of patients seen in the emergency department to better
identify patient concerns
D.Through staff development and weekly feedback, equalizing the likelihood that a patient will
receive the appropriate amount of pain medication regardless of their race
Answer : D
Explanation : The best answer is equalizing the likelihood that a patient will receive
pain medication as indicated regardless of race, ethnicity, or education. Equity is
about making sure patients receive appropriate, high-quality care regardless of
gender, race, ethnicity, socioeconomic status, geographic location, sexual
orientation, and other individual characteristics.
13. 191. Which of the following improvement efforts is the best example of making care more
patient centered?
A.Improving patient experiences by providing reading materials in the waiting room
B.Better identifying patient concerns and values by instituting quarterly patient focus groups
C.Decreasing unnecessary surgical procedures by helping patients reduce their pain through
physical activity
D.Improving the percent of clinic patients achieving their targeted blood pressure by
instituting a series of reminders for providers about evidence-based processes
Answer : B
Explanation : The best answer is implementing focus groups. Patient-centered care
means providing care that is respectful of and responsive to individual patient
preferences, needs, and values, and ensuring that patient values guide all clinical
decisions.
14. 192. Which of the following improvement efforts is the best example of increasing the
effectiveness of care?
A.Decreasing adverse drug events by having a pharmacist on rounds in the intensive care
unit
B.Improving the percent of clinic patients achieving their goal blood pressure by instituting a
series of reminders for providers about evidence-based processes
C.Shortening wait times at a clinic by allowing patients to self-register on a computer in the
waiting room
D.Instituting quarterly focus groups of patients seen in the emergency department to better
identify patient concerns
Answer : B
Explanation : A reminder system allowing providers to more easily use evidence in
a busy practice environment would best improve the effectiveness of care. Effective
care is based on scientific evidence and avoids underuse and overuse.
15. 193. Which of the following improvement efforts is the best example of increasing the
efficiency of care?
A.Improving patient experiences by providing reading materials in the waiting room
B.Improving the percent of clinic patients achieving their targeted blood pressure by
instituting a series of reminders for providers about evidence-based processes
C.Decreasing unnecessary surgical procedures by helping patients reduce their pain through
physical activity
D.Through staff development and weekly feedback, equalizing the likelihood that a patient will
receive pain medication regardless race, ethnicity, or education
Answer : C
Explanation :Decreasing unnecessary surgical procedures by helping patients
reduce their pain through physical activity is an example of more efficient care.
Efficient care means avoiding waste — including waste of equipment, supplies,
ideas, and energy.
16. 194. Why was it important for the Institute of Medicine (IOM) to develop its six aims for health
care?
A.So that accreditation organizations would be better able to evaluate hospitals
B.So that health care organizations would have a better idea of what they needed to improve
C.So that lawmakers could focus their attention upon specific areas when working on health
care reform
D.All of the above
Answer : B
Explanation : Just as defining dimensions of good performance helps employees,
defining the aims (or dimensions of quality) of health care helped hospitals and
other organizations understand what to focus on when improving their care.
19. 153. A patient with atrial fibrillation (heart arrhythmia), is placed on warfarin, a blood thinner, by his
cardiologist. He goes to clinic weekly to have his INR, a measure of how thin his blood is, checked.
One week he does not get a call after his bloodwork, and the week after he is admitted to the
hospital with a bleeding ulcer. His INR that night is 6, indicating his blood is dangerously thin.
A team conducts an RCA2. One root cause the team identifies is that the cardiology clinic does not
have a specific method to make sure they reach all patients with INRs and communicate abnormal
results and associated updates to their plan of care.
Which of the following is the best recommended action statement?
A.The nurse in charge of calling patients with their results should be replaced.
B.Patients need to have their INRs checked more frequently.
C.With a goal of 99% of patients receiving calls within 2 days of their results: Have the phlebotomy
lab automatically generate a list of all patients who had INRs drawn that day and email them to the
nurse, with space to note if the nurse has reached the patient with the results.
D.Patients awaiting lab results should be given access to MyChart, a part of the electronic health
record that allows them to access their lab results themselves.
Answer : C
Explanation :
Effective recommendations for action contain ideas for improving the system as well as
ideas for measurement. Answer C has both of these characteristics.
A is punitive and not systems-based, and B does not directly address the problem of the
lack of follow-up by the clinic.
D, although a good idea, does not contain a measurable outcome.
20. 154. The goals of measuring effectiveness, an important step in the RCA2 process, include:
A.Ensuring there's been compliance with the action items
B.Evaluating the effectiveness of the action items
C.Determining whether further corrective action is needed
D.All of the above
Answer : D
Explanation :
The best answer is all of the above. Process measures confirm the action has been
implemented, while outcome measures tell you if the action was effective. Both are
necessary and will help inform improvers if their changes are sufficient or further action is
warranted.
21. 155. Warning signs of an ineffective RCA2 include:
A.Human error is identified as causing the event.
B.Multiple corrective actions are identified.
C.The event review took longer than 25 days to complete.
D.All of the above
Answer : A
Explanation :If human error is identified as causing the event, the RCA2 was not conducted
properly. The Five Rules of Causation state that human error must always have a preceding
cause. Reviews may take up to 45 days and often yield several recommendations for
action.
22. 156. Causal statement example #1: "Residents are scheduled 80 hours per week, which led to
increased levels of fatigue, increasing the likelihood that dosing instructions would be
misread."
Is this a reasonable causal statement?
Yes
No
Answer : Yes. This is an effective causal statement.
157. Causal statement example #2: "The nurse made an error because the manual was poorly
written." .. Is this a reasonable causal statement?
Yes
No
158. Causal statement example #3: "The techs did not follow the procedure for CT scans, which led
to the patient receiving an air bolus from an empty syringe, resulting in a fatal air embolism."
Is this a reasonable causal statement?
Yes
No
Answer : No. Rule 2 states that there must be specific and accurate descriptors for what
occurred.
Rewrite: "The pump user manual had 8-point font and no illustrations. As a result, nursing
staff rarely used it, increasing the likelihood that the pump would be programmed incorrectly."
Answer : No. Rule 4 states that violations of procedure are not root causes, but must have a
preceding cause.
Rewrite: "Noise and confusion in the prep area, coupled with production pressures,
increased the likelihood that steps in the CT scan protocol would be missed, resulting in an
air embolism due to using an empty syringe."
23. 159. Which of the following is one of the Five Rules of Causation?
A.Human error must have a preceding cause.
B.In a hazardous environment, people have a responsibility to act safely.
C.Some effects have no identifiable cause.
D.Failure to follow procedure is often a root cause.
Answer : A
Explanation : The Five Rules of Causation include:
1.Clearly show the cause and effect relationship.
2.Use specific and accurate descriptors for what occurred.
3.Human error must have a preceding cause.
4.Violations of procedure are not a cause, but must have a preceding cause.
5.Failure to act is only causal when there is a pre-existing duty to act.
24. At your hospital, where you’re a patient safety officer, nursing staff members were providing routine
morning care to a patient. They were washing a patient who was seated in a chair. As this was taking
place, he slid off the chair, hitting his face, hip, and shoulder.
The patient was examined by a doctor at 7:55 AM and transferred to radiology for further evaluation.
The physician ordered x-rays and saw no fractures. Additional neurology checks were reported as
normal.
160.I. You are evaluating whether an RCA2 should be performed on this event. What would you say is
the actual severity of this event?
A.Catastrophic
B.Major
C.Moderate
D.Minor
Answer : Minor
Explanation : No injury was reported after evaluation by x-ray and clinical evaluation on the ward. Therefore, the
actual severity would be rated as minor.
160.II. What do you think is the potential severity of this event?
A.Catastrophic
B.Major
C.Moderate
D.Minor
Answer : Catastrophic
Explanation : The best answer is catastrophic. You should be able to imagine a worst case scenario in
which the patient’s fall results in a lethal injury.
25. At your hospital, where you’re a patient safety officer, nursing staff members were providing routine
morning care to a patient. They were washing a patient who was seated in a chair. As this was taking place,
he slid off the chair, hitting his face, hip, and shoulder.
The patient was examined by a doctor at 7:55 AM and transferred to radiology for further evaluation. The
physician ordered x-rays and saw no fractures. Additional neurology checks were reported as normal.
160.III. Assuming you judge the probability of a patient experiencing the most severe outcome as
“occasional,” should the organization proceed with RCA2?
Yes
No Answer :
Yes
26. 161. Which of the following scenarios would most likely call for RCA2?
A.An occupational therapist quits after only three days on the job.
B.A physician is convinced that there is a better way to deliver pain medications on her unit.
C.A social worker catches a patient who is falling out of bed.
D.An administrator needs to develop a balanced budget.
Answer : C
Explanation : RCA2 is important to address adverse events as well as near misses, such as
the near-fall in answer choice C, that indicate a potential for harm to patients.
Although the other options may represent opportunities for improvement, they are not
indicative of an imminent threat to patient safety and would not trigger RCA2.
27. 162. RCA2 can be useful in health care because:
A.It holds people accountable for their actions.
B.It helps to identify system failures that can be corrected.
C.It helps to assess the potential risk of introducing a new idea or process.
D.All of the above
Answer :B
Explanation :
RCA2 makes health care safer by focusing on systems failures and improving processes.
It does not blame individuals for their actions and is not a method for enforcing accountability.
It is not a method for assessing the risk of introducing a new idea or process.
28. 163. In regard to RCA2, “The chance of a specific event occurring; measured in terms of
consequences and likelihood” is the definition of:
A.Quality
B.Risk
C.Safety
D.Hazard
Answer : B
Explanation : This is a description of risk. As opposed to harm-based prioritization, RCA2
recommends using risk-based prioritization for responding to adverse events.
29. 164. What is the ultimate purpose of conducting RCA2 after an adverse event?
A.Doing a complete and thorough reconstruction of what happened before the event
B.Defining what should have happened for the patient
C.Creating a complete cause and effect diagram
D.Taking action to reduce the risk of future harm
Answer : D
Explanation : After you identify a safety problem within your system, the only way to make
the system safer and prevent future harm is by taking action. This is the ultimate goal of
RCA2.
The other answer options are steps along to way toward this ultimate goal.
30. 165. Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. An RCA2
team is exploring what happened. They consider characteristics of the patient and staff
members. What other areas should they consider?
A.Team factors
B.Work environment
C.Institutional context
D.All of the above
Answer : D
Explanation : The best answer is all of the above. A wide range of factors influence medical
outcomes, including: patient characteristics, task factors, individual staff member
characteristics, team factors, work environment, organizational and management factors,
and institutional context.
31. 166. Which of the following is a helpful tool/method for identifying underlying causes of
problems?
A.Five whys’ exercise
B.Cause and effect diagram
C.Harm-based prioritization matrix
D.‘Five whys’ exercise AND Cause and effect diagram.
Answer : D
Explanation : Cause and effect diagrams and the ‘Five Whys’ exercise are useful tools to
determine the root cause of a problem.
The Safety Assessment Code Matrix is a method for determining which adverse events
warrant close investigation.
167. Which of the following is a method for identifying underlying causes of specific problems?
A.Five whys’ exercise
B.Swiss cheese model of accident causation
C.Asking people in the system via 1:1 interviews why they believe an event occurred
D.All of the above
Answer : A
Explanation :
The ‘five whys’ exercise is a useful tool to help teams get to the root causes of problems by
persistently asking “why?”.
Effective interview questions focus on identifying what happened, not why.
The Swiss cheese model is a conceptual framework that is helpful to keep in mind as you
explore cause and effect but is not itself an investigative method.
32. 168. Which of the following is a recommendation for effective interviewing during RCA2?
A.Set the right tone by expressing your own regret about what happened.
B.Speculate why you personally believe the incident occurred.
C.The entire RCA2 team should be present at each interview to hear first-hand accounts.
D.Avoid writing questions ahead of time to keep an open mind.
Answer : A
Explanation : RCA2 interviews are often emotional and require sensitivity. To set the right tone
for the interview, especially with a patient or family member, it is appropriate to express your
regret that an unfortunate outcome or near miss occurred.
However, do not speculate at this point what caused the incident.
Each interview should involve only one or two RCA2 team members.
Ideally, the team should work together to prepare the interview questions ahead of time.
33. 169. Quinn is a three-year-old boy with a congenital heart malformation. While recovering in
the pediatric intensive care unit after surgical correction, he is accidentally given ten times
the appropriate dose of heparin. Although he suffers no permanent injuries, the leaders of the
hospital decide to conduct a RCA2.
As they assemble the team, which of the following would you recommend?
A.Put together a team that mostly includes nurses and physicians.
B.Include Quinn’s parents.
C.Create a team of members who fulfill several roles.
D.Include the health care providers involved in Quinn’s care.
Answer : C
Explanation :
RCA2 teams need to be diverse in order to be able to see as many viewpoints as possible.
The patient and family, as well as the providers, involved in the event should not be
included in the RCA2 teams, although they should be kept informed of the progress.
Inter-professional teams are strongly encouraged, but there is no hard-and-fast
prescription for which professions should be included or what the balance of the
professions should be.
Ideally, the team will include people with a strong understanding of the areas and
processes involved in the case.
34. 170. What should leadership teams do to support the RCA2 process?
A.Make sure there is at least one member of senior leadership on the team.
B.Wait to conduct the RCA2 review for at least 30 days, to let the emotions surrounding the
incident subside.
C.Make sure the RCA2 team has designated time to conduct a thorough review.
D.All of the above
Answer : C
Explanation : Conducting a high-quality RCA2 review takes time, and leadership needs to
ensure team members have time to devote to RCA2 tasks as part of their work.
Senior leadership does not need to be on the core investigative team; in fact, senior
leaders may be an impediment to drawing candid answers out of front-line staff.
RCA2 activities should be conducted quickly, before memories fade and attention is turned
to newer problems.
35. 171. An RCA2 team is launching an investigation of a surgical error. If they complete an
effective review, which of the following is an example of a root cause they might identify?
A.The surgeon did not listen to the nurse.
B.The patient was male.
C.The hierarchy in the operating room had a negative effect upon communication.
D.All of the above
Answer : C
Explanation : RCA2 is meant to identify system failures that place patients at risk. Poor
communication due to hierarchy is an example of an inherent problem in the system that
could cause it to fail. If the surgeon failed to listen to the nurse, it would be a symptom of
this larger problem.
37. 172. As a caregiver, which of the following common health IT issues would you be in the best
position to help solve?
A.Incomplete data entries into the computer
B.Delays due to connectivity issues
C.Out-of-date software
D.None of the above
Answer : A
Explanation : The best answer is incomplete data entries into the computer, which is a
human-computer issue (as opposed to a computer issue). User feedback from caregivers is
critical to improve the interfaces between computers and humans.
38. 173. You enter a medication order in your hospital's EHR, and a warning screen pops up
saying that your patient's medication dose should be adjusted based upon her last lab
results. However, you know that the patient had a lab draw more recently — recorded at a
different clinic and therefore not available in your EHR — that showed different values. When
you attempt to move past the warning, the system will not allow you to proceed.
What does this block best exemplify?
A.How technology can be used to make patient care safer
B.How technology can be used to make care more efficient
C.How technology that dictates your work — rather than facilitates it — can introduce
unintended problems
D.A and B (How technology can be used to make patient care safer AND How technology can
be used to make care more efficient)
Answer : C
Explanation : In this case, the system appears to be problematic because it does not allow
for the fact that there will sometimes be additional information that caregivers must take
into account, and tries to force caregivers to follow rigid rules. A situation of this kind is
inefficient and likely to result in a workaround that may make patients less safe.
39. 174. Which of the following is the best example of using technology to improve safety and
prevent errors?
A.Providing inpatients with electronic tablets so that they can keep in better touch with the
outside world
B.Giving nursing assistants electronic tablets to ensure there’s no delay in recording
patients’ vital signs
C.Implementing redundancies, in which providers double-check each other’s electronic
inputs
D.Switching to an electronic health record (EHR) platform that is of comparable quality but
lower cost
Answer :B
Explanation : Using tablet technology to allow nursing assistants to record vital signs
immediately is an example of using technology to make work safer. When vital signs are
recorded much later than they’re observed, the opportunities for error increase.
Giving patients tablets may improve their inpatient experiences, but isn’t as likely to prevent
errors.
Switching to a lower cost EHR platform may make good business sense, but that decision won’t
directly affect patient safety.
If providers are checking each other’s work that can make care safer, but it’s a social
redundancy rather than a technology-based redundancy.
40. 175.I. How does this technology help make her care safer?
A.The pump eliminates the need for providers to be involved in her care.
B.The pump eliminates the possibility of a medication error.
C.The pump helps automate a complex care process
D.All of the above
Answer : C
Explanation : The pump automates the complex process of precisely administering insulin at
regular intervals, helping make care safer for the patient. However, there’s the chance the
pump could malfunction, and providers dictate dosing decisions, so errors could still occur.
Providers must always be present to ensure proper and effective use of technology.
You’re caring for a patient with diabetes who was admitted to your hospital with an elevated
blood glucose level. She is on an insulin pump that is programmed to deliver one unit of
insulin per hour through her intravenous (IV) line.
175.II. Which of the following is a risk of this technology?
A.The pump is dictating rather than facilitating your work.
B.The pump could malfunction.
C.There is no risk associated with the pump.
D.A and B (The pump is dictating rather than facilitating your work AND The pump could malfunction)
Answer : B
Explanation : Although the pump helps facilitate your work by automating the process of
delivering a precise amount of insulin at regular intervals, there is always some chance it could
malfunction.
Remember, human beings must still be very present when interacting with technology to ensure
its proper and effective use.
41. 176. Which of the following statements about bar-cording systems is true?
A.They typically offer few benefits and merely promote workarounds.
B.They can completely prevent medication errors.
C.They can help providers keeps track of laboratory specimens, identify medications and
medical equipment, and identify patients.
D.B and C (They can completely prevent medication errors AND They can help providers
keeps track of laboratory specimens, identify medications and medical equipment, and
identify patients.)
Answer : C
Explanation : Bar-coding systems can help identify medications and match them to the
correct patient, as well be used to label and track laboratory specimens, identify medical
equipment, and identify patients.
Despite these significant benefits, bar-coding systems have potential flaws, and can
promote workarounds if not designed properly.
42. 177. Effective ways for addressing defects in the human-technology interface include:
A.Providing in-person user training on using the technology
B.Testing the technology in real-world situations
C.Encouraging users to find workarounds
D.All of the above
Answer : B
Explanation : Once designed, actual users should test technology in real-world situations. If
users don’t test the technology, then the possibility of introducing a faulty system goes up,
which additional training would not address.
Workarounds can lead to serious error; you should view them as a symptom of a poorly
designed or overly complex system.
178. Effective ways for addressing defects in the human-technology interface include:
A.Involving the user in the design of the technology
B.Testing the technology under real-life conditions
C.Reducing the cost of the technology
D.A and B
Answer: D
Explanation : When developing or trying out a new technology, it’s essential to test the
technology in the environment in which it will be used. It’s also essential to involve those
who will use the technology in its design. In the absence of these steps, it’s possible that
serious design problems will surface later — in a way that could hurt patients.
Attending to cost will not improve the interface between technology and the humans who
will use it.
43. 179. You’re working in an outpatient clinic that recently started using an electronic health record
(EHR). You are entering a prescription for an antibiotic into the EHR to treat Mrs. Jones’s urinary
tract infection. As you enter the order, a warning screen pops up saying that she has chronic
kidney disease, and the medication dose should be adjusted based upon her last recorded
creatinine level (a measure of kidney function). However, you know that Mrs. Jones’s most recent
creatinine level — recorded at a different clinic and therefore not available in your EHR — came
back normal. When you attempt to move past the warning, the system will not allow you to
proceed.
Which of the following concepts does this scenario demonstrate?
A.Technology can introduce unintended problems.
B.Technology should facilitate how you do your work, not dictate it.
C.Human beings must still be very present when interacting with technology to ensure its proper
and effective use.
D.All of the above
Answer : D
Explanation : All of the above is the best answer. In this case, the computer has
information, but not all of the information.
The system does not seem to allow for the fact that there will sometimes be additional
information that caregivers must take into account. Instead, it tries to force caregivers to
follow rigid rules.
Remember: Human beings must still be very present when interacting with technology to
ensure its proper and effective use.
44. 180. Careful application of human factors and user testing during device design are necessary
to identify and correct device attributes that increase the potential for human error. Until FDA
demands better-designed devices and forces redesign or removal of unsafe devices currently
on the market, implementing all of the following recommendations can enhance safety except:
A.use patient controlled analgesia (PCA) pumps that read bar codes to automatically set the
concentration
B.carefully position syringe labels so that important drug information can be seen readily
during pump setup and infusion
C.monitor patients frequently and have antidotes readily available.
D.use pumps with a priming function
Answer : D
Explanation :
To the contrary, avoid using pumps with a priming function that can deliver a bolus
during infusions. When new devices are purchased, use failure mode and effects
analysis (ask what could go possibly wrong) to identify design flaws and all points at
which user error might occur so that proactive safety measures can be taken.
