A patient at Your Hospital is Sent to a Cardiology for a routine test

A patient at your hospital is sent to cardiology for a routine test. The patient returns without incident and you document the time and condition of the patient upon return to the room. The next day you are summoned to the unit manager’s office, along with the charge nurse and unit secretary. 

The manager describes how the patient’s chart had a different patient’s face sheet and blue plate. The manager demands an explanation for the incident since controls are in place that should eliminate problems such as this (all patient charts going off the floor for procedures must be checked by the both nurse and unit secretary for proper blue plate and face sheet). This procedure is in place due to similar incidents on other floors.

Who should you contact to conduct the analysis?
Group of answer choices

the charge nurse

the unit manager

the unit secretary

the risk manager

Question 2

Who should the analysis include? Select ALL that apply.
Group of answer choices

the unit manager

the charge nurse

the unit secretary

the nurse

Question 3

The investigation discovered that there were 12 admits and discharges occurring around the time of the incident, with only one unit secretary. The nurse was admitting a complicated patient with multiple needs when the patient left for the procedure. Based on this information, where could the fault lie?
Group of answer choices

the secretary

the nurse

the process

the unit manager

Question 4

What possible suggestions could you make to decrease the possibility of a similar incident?
Group of answer choices

Have all charts checked during the midnight shift or upon admission for correct identifiers.

If transport or the nursing assistant takes the patient, then the individual transporting the patient could check the chart.

Both answers shown.

Neither answer shown.

Question 5

Which The Joint Commission’s patient safety goal was addressed in this case study?
Group of answer choices

Goal 15: The hospital identifies safety risks inherent in its patient population. Identify patients at risk for suicide.

Goal 1: Improve the accuracy of patient identification. Using two identifiers when providing treatments or procedures.

Goal 2: Improve the effectiveness of communication among caregivers. Report critical results of tests and diagnostic procedures on a timely basis.
Flag question: Spacer
Case Study #2 
For Questions 6 and 7

A recent trend identified by TJC concerns hospital discharge procedures for congestive heart failure patients. Seven elements are required for each discharge: diet, fluid restriction, activity level, when to call a physician, time for the follow-up appointment, clear medication directions, and specific signs and symptoms of CHF problems (peripheral edema, shortness of breath, activity intolerance). The quality assurance team is charged with achieving 100% compliance with indicators for each aspect of the discharge process.

Question 6

The seven specific discharge instructions are the quality indicator in this scenario.
Group of answer choices



Question 7

Select ALL the procedures that need to be implemented in order to achieve compliance with regard to staff nurses.
Group of answer choices

Educate staff nurses on easch aspect of the CHF discharge process.

Develop an understanding of the need for compliance and rationale for the changes.

Disseminate finding to all staff nurses.

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