|
| A) | True | ||
| B) | False |
The IOM Committee on Quality of Healthcare in America defines error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim" [1]. It is important to note that medical errors are not defined as intentional acts of wrongdoing and that not all medical errors rise to the level of medical malpractice or negligence. Errors depend on two kinds of failures: either the correct action does not proceed as intended, which is described as an "error of execution," or the original intended action is not correct, which is described as an "error of planning" [1]. A medical error can occur at any stage in the process of providing patient care, from diagnosis to treatment, and even while providing preventative care. Not all errors will result in harm to the patient. Medical errors that do result in injury are sometimes called preventable adverse events or sentinel events—sentinel because they signal the need for immediate investigation and response [6].
| A) | True | ||
| B) | False |
Beginning January 1, 2027, the Joint Commission aligned its Sentinel Event List with the National Quality Forum (NQF) Serious Reportable Events (SRE) framework. The Joint Commission's Sentinel Event List includes the NQF Serious Reportable Events together with three workforce safety events retained by the Joint Commission. These events are organized into the following broad categories:
Procedural events: Events associated with surgical or other invasive procedures, such as surgery or an invasive procedure performed on the wrong patient or wrong body site, the wrong procedure performed, or the unintended retention of a foreign object following an invasive procedure.
Product or device events: Events involving the use or function of medical devices, biologics, or blood products that result in serious patient harm, including preventable transfusion-related events caused by major blood group incompatibilities.
Patient protection events: Events that compromise patient safety through failures in protection or security, including patient suicide associated with healthcare settings, infant discharge to the wrong family, patient abduction, or other serious failures to protect vulnerable patients.
Care provision events: Preventable events related to the delivery of healthcare, including certain medication errors, diagnostic or treatment delays, maternal or neonatal events, patient falls resulting in serious harm, and other preventable adverse events that meet the criteria for serious reportable events.
| A) | True | ||
| B) | False |
The Joint Commission will consider a root cause analysis acceptable for accreditation purposes if it focuses primarily on systems and processes, not individual performance [6]. In other words, the healthcare organization should minimize the individual blame or retribution for involvement in a medical error. In addition, the root cause analysis should progress from special causes in clinical processes to common causes in organizational processes, and the analysis should repeatedly dig deeper by asking why, then, when answered, why again, and so on. The analysis should also identify changes that can be made in systems and processes, either through redesign or development of new systems or processes, which would reduce the risk of such events occurring in the future. The Joint Commission requires that the analysis be thorough and credible. To be considered thorough, the root cause analysis must include [6]:
A determination of the human and other factors most directly associated with the sentinel event and the process(es) and systems related to its occurrence
Analysis of the underlying systems and processes through a series of "why" questions to determine where redesign might reduce risk
Inquiry into all areas appropriate to the specific type of event
Identification of risk points and their potential contributions to this type of event
A determination of potential improvement in processes or systems that would tend to decrease the likelihood of such events in the future, or a determination, after analysis, that no such improvement opportunities exist
| A) | True | ||
| B) | False |
To be considered credible, the root cause analysis must meet the following standards [6]:
The organization's leadership and the individuals most closely involved in the process and systems under review must participate in the analysis.
The analysis must be internally consistent; that is, it must not contradict itself or leave obvious questions unanswered.
The analysis must provide an explanation for all findings of "not applicable" or "no problem."
The analysis must include consideration of any relevant literature.
| A) | True | ||
| B) | False |
Healthcare professionals have an obligation to report adverse events to leadership and ensure that organizations have processes in place to satisfy the Joint Commission requirement. In Florida, certain serious adverse incidents must also be reported to Florida's Agency for Health Care Administration (AHCA). Florida law requires that licensed facilities, such as hospitals, establish an internal risk management program. As part of that program, licensed facilities must develop and implement an incident reporting system, which requires the development of appropriate measures to minimize the risk of adverse incidents to patients, as well as imposes an affirmative duty on all healthcare providers and employees of the facility to report adverse incidents to the risk manager or to his or her designee. The risk manager must receive these incident reports within 3 business days of the incident, and depending on the type of incident, the risk manager may have to report the incident to AHCA within 15 days of receipt of the report.
| A) | True | ||
| B) | False |
Unlike Florida's mandatory reporting of serious adverse incidents, the Joint Commission recommends that healthcare organizations voluntarily report sentinel events, and it encourages the facilities to communicate the results of their root cause analyses and their corrective action plans. As a result of the sentinel events that have been reported, the Joint Commission has compiled Sentinel Event Alerts. These alerts are intended to provide healthcare organizations with important information regarding reported trends and, by doing so, highlight areas of potential concern so an organization may review its own internal processes to maximize error reduction and prevention with regard to a particular issue [7].
| A) | True | ||
| B) | False |
In 2024, the Joint Commission reviewed 1,575 sentinel events [11]. Some events, such as fire, impacted multiple patients. Sentinel event reviews during this time period were frequently conducted for patient fall; delay in treatment; unintended retention of a foreign body; wrong-patient, wrong-site, wrong-procedure surgery; patient suicide; operative and postoperative complications; and medication error [11].
| A) | True | ||
| B) | False |
The most common root cause documented for patient suicide reported between 2010 and 2014 was shortcomings in assessment, most commonly psychiatric assessment [18]. Joint Commission data indicate that approximately 21% of accredited behavioral healthcare organizations and 5% of accredited hospitals were found to be noncompliant with suicide risk assessment requirements during accreditation surveys.
| A) | True | ||
| B) | False |
Unquestionably, medication errors are one of the most common causes of avoidable harm to patients. These errors may occur at any of these critical points: when ordered or prescribed by a physician; during documentation; while transcribing; when dispensed by a pharmacist; when administered by a nurse; or during monitoring.
| A) | True | ||
| B) | False |
The early detection and diagnosis of cancers is crucial for selecting the appropriate treatment approach and to ensure an optimum outcome. However, some studies of specific cancers and diagnostic pathways have reported error or missed-opportunity rates exceeding 10%, and the missed or delayed diagnosis of cancers remains a significant cause of medical malpractice claims [30,31]. The causes of missed diagnoses vary widely among cancers in different parts of the body. In many cases, patients who do not fit the typical profile for a specific cancer (e.g., young age) may be underdiagnosed, and it is important that cancer is considered as part of the differential diagnosis in ambiguous cases [31,32,33]. In order to prevent missed or delayed cancer diagnosis, practitioners may take steps to ensure adherence to clinical guidelines for screening and diagnosis, use tools to facilitate communication, and engage strategies to ensure appropriate follow-up [55].