Post-Lesson Assessment

Assessment Review
Status
Question
!
1) What did James Reason call a series of errors along multiple steps in a
process that lined up to and led to an unintended consequence?
Your Answer:d) The Swiss cheese model
Correct Answer:d) The Swiss cheese model
The Swiss cheese model, coined by James Reason, refers to a situation in which
a series of errors along multiple steps in a process all line up to lead to an
unintended consequence.
!
2) Which of the following statements is true?
Your Answer:d) None of the above
Correct Answer:d) None of the above
Not all errors reach patients or cause harm; however, organizations must still
learn from these as there may be opportunities to improve processes.
Sometimes there is not a clear source of error; however, that does not diminish
the harm experienced by the patient. Organizations must always consider these
events as opportunities to make the system better.
!
3) Which of the following is part of a systems approach to addressing
error?
Your Answer:b) Recognizing that most errors are not due to negligent
individuals
Correct Answer:b) Recognizing that most errors are not due to negligent
individuals
A systems approach involves recognizing that the design of systems and
processes are the major contributors to errors, not the individuals working within
those systems. To improve, there must be examination of these systems
processes, procedures, equipment, and organizational culture that can lead to
error. We shouldnt consider patient harm as simply unavoidable, but continually
strive to improve.
!
4) Errors that lead to serious patient harm are _____ the result of just one
error involving one person.
Your Answer:b) Rarely

Correct Answer:b) Rarely

Errors that lead to serious patient harm are rarely the result of just one error
involving one person. Rather, there are typically a series of errors or breakdowns
in process, most of which have probably been occurring for some time, just not
all at once.
!
5) Which of the following is an example of an error in daily life?
Your Answer:d) All of the above
Correct Answer:d) All of the above
The best answer is all of the above. Making errors is a frequent occurrence in
daily life. Sometimes they result in harm, and sometimes they dont. In fact,
sometimes you never even realize you made the error!

Percentage Correct: 100%

Lisa

Post-Lesson Assessment
Assessment Review
Status
Question
!
1) Which of the following is an endogenous (internal) cause of the
residents error?
Your Answer:b) Fatigue
Correct Answer:b) Fatigue
The correct answer is fatigue. Internal causes of errors also called
endogenous causes include both psychological states (anger, fear, boredom,
anxiety) and physiological states (fatigue, illness) that cloud our judgment and
thought processes. Alternatively, long work schedules or inadequate training
would be external causes of error also called exogenous causes.
!
2) To prevent this problem from happening again, which of the following
would be the best course of action?
Your Answer:c) Develop a system that prevents messy handwriting from
causing miscommunication that leads to error.
Correct Answer:c) Develop a system that prevents messy handwriting from
causing miscommunication that leads to error.

The best answer is to develop a system that prevents messy handwriting from
causing confusion that leads to error. For example, the organization could switch
to an electronic ordering system. Mandating additional training and/or punishing
the resident and pharmacist for an unintentional error wont prevent them or
anyone else from making the same mistake in the future. Providers are human
beings, and there will always be days when theyre tired or distracted.
!
3) Latent errors are best defined as:
Your Answer:a) Defects in the design and organization of processes and
systems.
Correct Answer:a) Defects in the design and organization of processes and
systems.
Latent errors are defects in the design or organization of processes and systems.
These insidious errors can go unnoticed or ignored, but in time are likely to result
in patient harm or, a so-called active error in care. For example, operating on
the wrong surgical site is an active error with immediate effects; however, any
number of latent errors in surgical processes can contribute to a wrong-site
surgery.
!
4) What is the active error in this scenario?
Your Answer:b) The nurse administers an antibiotic to Ms. Tyler and a sedative
to Ms. Taylor.
Correct Answer:b) The nurse administers an antibiotic to Ms. Tyler and a
sedative to Ms. Taylor.
The active error is the human error that led to patient harm. In this case, its the
nurse administering an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.
!
5) What is one of the latent errors in this scenario?
Your Answer:c) The forms are completed by hand at the same time for different
patients.
Correct Answer:c) The forms are completed by hand at the same time for
different patients.
Latent errors include any systemic problems that allowed the potential for an
active error to occur and lead to patient harm. In this case, the fact that the forms
were completed by hand at the same time for different patients turned out to be a
latent error. The busy department and patients with similar names were not
errors; they are just inherently challenging qualities of the system.

Percentage Correct: 100%

Congratulations. Your current score is sufficient to successfully complete
this lesson.
Please click the "Complete Lesson" link below.

Post-Lesson Assessment
Assessment Review
Status
Question
!
1) Approximately what percent of medical harm is caused by incompetent
or poorly intended care?
Your Answer:a) <10%
Correct Answer:a) <10%
Only about 5 percent of medical harm is caused by incompetent or poorly
intended care. That means 95 percent of medical harm involves conscientious,
competent individuals involved in circumstances that lead to a catastrophic
result. Consequently, blaming and punishing an individual does not address the
underlying issues that led to an event and does not prevent a recurrence.
!
2) Which of the following statements is true?
Your Answer:c) Blaming and punishing an individual for making an error can be
appropriate if that individual intentionally caused harm.
Correct Answer:c) Blaming and punishing an individual for making an error can
be appropriate if that individual intentionally caused harm.
There are some rare cases when it may be appropriate to blame and punish an
individual who deliberately ignored protocol or intentionally caused harm.
However, this is a small minority of cases. Blame and punishment can never
undo or prevent errors, nor can they prevent errors from happening.
!
3) A colleague accesses and delivers a medication, believing it is the
correct one. Unfortunately, it isnt it is another medication in a similar
vial. Which of the following is the best way to address his error?
Your Answer:d) Investigate whether others find the vials confusing and consider
making a change to how they are packaged or accessed.
Correct Answer:d) Investigate whether others find the vials confusing and
consider making a change to how they are packaged or accessed.
The best answer is to investigate the source of the error and consider making a
change to the system, such as how the medications are packaged or accessed.
Learning from an error and putting systems in place to prevent the error is the
only effective way to reduce the likelihood the error will happen again.
!
4) When an error occurs, which of the following is a productive response?

Your Answer:d) A and C

Correct Answer:d) A and C
A and C are productive responses to error. Determining if reasonable changes
can be made to prevent the same type of error in the future is a great response
after an error occurs. Note that when interviewing participants about the error, the
goal should be to understand what happened not to determine fault or place
blame.
!
5) Which of the following situations seems to warrant punitive action?
Your Answer:a) A colleague routinely refuses to perform a mandatory safety
process.
Correct Answer:a) A colleague routinely refuses to perform a mandatory safety
process.
In rare cases, such as where protocol is deliberately being ignored, punitive
action may be warranted. However, most errors are the result of unintentional
situations. For instance, its easy to be distracted in a fast-paced setting. If your
colleague has made the same error more than once, it is, most likely, an easy
error to make. (You may find others making it, too.) This is why we need strong
systems in place to protect us.

Percentage Correct: 100%

Congratulations. Your current score is sufficient to successfully complete
this lesson.
Please click the "Complete Lesson" link below.

Post-Lesson Assessment
Assessment Review
Status
Question
!

1) Which of the following are ways an institution can capture data about
errors?
Your Answer:d) All of the above
Correct Answer:d) All of the above
Within automated systems such as bar-coding systems, smart pumps, or
computerized physician order entry systems technology can be designed to
identify errors and capture information about those errors. Organizations can also
use voluntary reporting systems to capture information about errors.

2) Which of the following is most consistently true about voluntary error

reporting systems?
Your Answer:b) Any hospital staff can complete and submit a report.
Correct Answer:b) Any hospital staff can complete and submit a report.
While all voluntary reporting systems are different, in most cases anyone
(employees, physicians, and sometimes patients and families) can complete and
submit a voluntary error report at any time. Voluntary reporting systems can take
many forms, including paper-based or computerized forms or hotlines. Voluntary
reporting systems can be anonymous or open, depending on the organization
and the level of transparency around the issue of errors.
!
3) Which of the following statements is true?
Your Answer:a) Its important to report errors.
Correct Answer:a) Its important to report errors.
Its important to report errors; however, voluntary error reporting systems have
some significant limitations, so organizations must be careful when interpreting
voluntarily reported error data. For instance, if the number of errors recorded
increases, it could be a result of a greater percent of errors being reported, rather
than more errors occurring.
!
4) Which of the following factors contributes to errors being
underreported?
Your Answer:d) All of the above
Correct Answer:d) All of the above
The best answer is all of the above. Despite inherent flaws in voluntary reporting
systems, data from those systems can give an organization a sense of the types
of issues occurring within its walls, and create opportunities for learning and
improvement.
!
5) Should you report what happened?
Your Answer:d) Yes, because it may indicate an opportunity to improve that
process.
Correct Answer:d) Yes, because it may indicate an opportunity to improve that
process.
You should report the error. Heres why: Even if an error does not affect the
outcome of what you are doing, it stills represents an opportunity to improve a
process; in order to improve, these errors must be recognized and made known
so they can be analyzed as appropriate. It is very unlikely anyone should be
reprimanded in this scenario, as there does not appear to be any intentional
disregard for safety.

Percentage Correct: 100%

Congratulations. Your current score is sufficient to successfully complete

this lesson.
Please click the "Complete Lesson" link below.

Post-Lesson Assessment
Assessment Review
Status
Question
!
1) Which of the following statements is true?
Your Answer:c) Organizations should always consider situations in which harm
occurs as opportunities to learn.
Correct Answer:c) Organizations should always consider situations in which
harm occurs as opportunities to learn.
Not all errors reach patients or cause harm; however, organizations must still
learn from these as there may be opportunities to improve processes.
Sometimes there is not a clear source of error; however, that does not diminish
the harm experienced by the patient. Organizations must always consider these
events as opportunities to make the system better.
!
2) What is the Swiss cheese model?
Your Answer:b) When a series of errors along multiple steps in a process all line
up to lead to an unintended consequence
Correct Answer:b) When a series of errors along multiple steps in a process all
line up to lead to an unintended consequence
The Swiss cheese model, coined by James Reason, refers to a situation in which
a series of errors along multiple steps in a process all line up to lead to an
unintended consequence.
!
3) What is a systems approach to addressing error?
Your Answer:a) Recognizing that the design of systems and processes, not
individuals, are the major reason for error
Correct Answer:a) Recognizing that the design of systems and processes, not
individuals, are the major reason for error
A systems approach involves recognizing that the design of systems and
processes are the major contributors to errors, not the individuals working within
those systems. To improve, we must examine these systems processes,
procedures, equipment, and organizational culture that can lead to error. We

shouldnt consider patient harm as simply unavoidable, but continually strive to

improve.
!
4) Which of the following is an example of an error in daily life?
Your Answer:d) All of the above
Correct Answer:d) All of the above
The best answer is all of the above. Making errors is a frequent occurrence in
daily life. Sometimes they result in harm, and sometimes they dont. In fact,
sometimes you never even realize you made the error!
!
5) Errors that lead to serious patient harm are _____ the result of just one
error involving one person.
Your Answer:c) Rarely
Correct Answer:c) Rarely
Errors that lead to serious patient harm are rarely the result of just one error
involving one person. Rather, there are typically a series of errors or breakdowns
in process, most of which have probably been occurring for some time, just not
all at once.

Percentage Correct: 100%

Congratulations. Your current score is sufficient to successfully complete
this lesson.
Please click the "Complete Lesson" link below.