1. You are educating clinical managers in your healthcare facility on how
to identify appropriate events for conducting a Root Cause Analysis. Which event
provides the best opportunity for an RCA?:
a. A post-op patient removeshis own IV causing a skin tear from the tape
b. A patient with no known allergies experiences an anaphylactic reaction to an
antibiotic requiring transfer to ICU.
c. The biopsy samplesfrom a colonoscopy are never received by pathology after the
procedure
d. There have been 3 occurrences of depressed respirationsin the same departmentin
the last 4 months related to sedation
Answer C
2. The instrument count is incorrect at the conclusion of a surgical procedure. The
hospital policy does notstipulate that the surgeon remain on the premisesuntil an x-ray
is obtained. The surgeon leaves the hospital to catch a flight. The x-ray reveals a
retained instrument. Another surgeon is contacted to remove the retained instrument.
What should leadership do next?:
a. Create a processmap of how instruments are managed during surgery looking for
latent flaws
b. Revise the hospital policy to make it clear that surgeons must stay in the OR until
instrument count issues are resolved
c. Counsel the surgeon about customary clinical standards for a surgeon using
appropriate accountability system
d. Reeducate the OR nursing staff on keeping track ofinstruments on the sterile field
Answer C
3. A nurse on a medical-surgical unit does not comply with barcode medica- tion
administration (BCMA) while caring for one of her patients. What should her
supervisor do?:
a.Ask staff if there are adequate scannersto meet their needs
b. Counsel the nurse on the importance of following policy
c. Request that the pharmacy run a report of BCMA compliance rates of the unit
d. Ask the nurse what was occurring at the time, and why she chose to bypass the
polic
Answer D
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