NUR2833C Nursing Quality and Safety
Final Exam – 50 questions
Chapter 1: Driving forces for quality and safety
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What are the steps in quality improvement - Identify problems, apply quality
improvement tools to collect data, analyze results, design solutions, close the gap
between actual and desired practice
Textbox 1:1 page 5 Summary of the IOM reports (know the basic summary of these
reports)
QSEN competencies: know what QSEN and KSA’s stand for and why QSEN was
formed in relation to KSA’s
Definition of an error, different types of errors, Swiss Cheese Model of adverse events
Barriers and challenges nurses face to quality and safety
Chapter 4 – Patient-centered care
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What is Patient-centered care (PCC), and benefits
4 core principles of patient and family centered care (PFCC): Dignity and Respect,
Information sharing, Participation, Collaboration (know examples of these)
HCAHPS and know some examples of what is measured
Chapter 5 – Teamwork and collaboration
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Definitions team, teamwork, collaboration, interprofessional teams
Communication strategies: back-up behavior, SBAR, Call-out, Check-back, handoff,
closed-loop
Challenges and benefits to communication
TeamSTEPPS model
Chapter 6 – Quality Improvement
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Steps involved in Quality Improvement
QI process and examples of tools used in the process (PDSA, RCA)
Triple Aim, HCAHPS
Chapter 7 – Evidence-based practice
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Definition, goals and purposes
Key components, steps in process and practice
Barriers and nurse’s role
Chapter 8: Safety
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Definition of an error
Categories of errors/failures (latent, active, indirect, technical), know examples of these.
Differences between the following errors: lapse, slip and mistake
Nine (9) categories that provide opportunities to improve patient safety and examples of
these
Difference between RCA and FMEA
Challenges to patient safety
Chapter 14: Interprofessional approaches to quality and safety education
 IPE – why is this important and what are the six broad themes
 Core competencies – values/ethics for interprofessional practice, roles/responsibilities,
interprofessional communications, teams and team works (know the description of
these)
 Core features that contributes to successful interprofessional learning (Cooperative,
reflective, experiential and promotion/transfer learning) - know examples of theses
Chapter 16: Leadership to create change
Know Medication reconciliation process
Collaborative Partner Presentations Review – Powerpoint (lots of questions from here)
Definition and examples of Adverse events
Sentinel events
Adverse events responses 2nd victim phenomenon
RCA process
FMEA process Tall man Lettering
Comprehensive Unit-based Safety Program (CUSP)
Hospital Acquired Infections (HAI’s) what are these and examples
The Joint Commission and National Patient Safety Goals – purpose
Just culture and patient safety
IHI (Refer to BB student resources for summary of these)
IHI PS 101: Introduction to patient safety
Lesson 1: Understanding Adverse events and Patient Safety
Importance of studying the field of patient safety
Why is health care dangerous and how to make changes
Lesson 2: Your role in a culture of safety
Blaming and punishing
Lesson 3: Your role in building safer, more reliable systems. Call to action – what can you do (4
behaviors to improve patient safety)
IHI PS 102: From Error to Harm
Lesson 1 Swiss Cheese Model – Latent conditions vs active failures (know what these are and
examples)
Lesson 2 Understanding Unsafe Acts
Difference between error and violation
Unsafe acts: error, slip, lapse, mistake (examples of these)
What is a Central Line and associated infection?
Lesson 3 A closer look at harm - IHI definition of harm
IHI PS 103: Human Factors and Safety
Lesson 1 Understanding the Science of Human Factors
What are internal and external factors that make it more prone to errors
What is heuristics?
Lesson 2 Design Principles to Reduce Human Errors
The 8 effective principles for error-reduction designs (know examples of these)
Lesson 3 The Risks and Rewards and Technology
IHI PS 104: Teamwork and Communication
Lesson 1 Why are teamwork and communication important and the fundamentals of teamwork
and communication
Lesson 2 Tools and techniques for effective communication (critical language, 2-challenge rule,
briefings, debriefing, SBAR, repeating back) know examples of these
Lesson 3 Safety during transitions
Characteristics of a culture of safety (psychological safety, active leadership, transparency,
fairness)
IHI PS 105: Responding to Adverse Events
Lesson 1 Responding to an adverse event, step-by-step approach (know the 4 steps)
Lesson 2 Communication apology and resolution (4 components of an effective apology)
How do you apologize after a medical error?
Lesson 3 The impact of adverse events on caregivers: The second victim
Review Video’s
Josie King: What are the factors that contributed to Josie’s death?
Annie’s story – how a system’s approach can change safety culture
Articles:
Nurse gives patient paralytic instead of antacid – medication administration process, rights of
medication administration