Felicia Lee 11/22/24

(Total time = 100 minutes, 1 question at a time; no backtracking) Approximately 56- 62 questions

Concept Questions

Healthcare Law (Overview) Approximately

 Have a generalized understanding of the specific laws listed below ( 3 – 5 questions) 15 questions

Patient Self-Determination Act: patient must be informed in writing on their

right to accept of refuse treatment and the right to an advance directive.
Emergency Medical Treatment and Active Labor Act: ensure public access to
emergency services regardless of ability to pay.
Good Samaritan Act: offers limited protection to someone who attempts to
help a person in distress - if a medical professional, confined to scope, and
cannot abandon pt until medical help arrives (once you start, you can't stop)
Affordable Care Act: make affordable health insurance available to more
people/uninsured
Uniform Anatomical Gift Act: encourages organ donation - allows decedent or
surviving relatives to donate certain organs for research or transplantation. A
federal framework that sets how anatomical gifts can be made.
Americans with Disabilities Act: civil rights law that prohibits discrimination
against individuals with disabilities in all areas of public life (jobs, schools,
transportation, public/private places that are open to public)
Mental Health Parity and Addiction Equity Act: requires most health
plans/insurers that offer coverage for mental health conditions or substance
abuse disorders make these benefits comparable to med/surg benefits.
Comprehensive coverage for mental health and substance abuse disorders.
Omnibus Budget Reconciliation Act: OBRA - meant to improve quality of life
and safety of nursing home residents. Regulated use of restraints to manage
patient behavior - knowing when and how to use restraints - protects rights of
nursing facility residents (same rights as everyone else).
 Be familiar with Tort Law (you will be given patient –nurse scenarios and you will need
to identify the type of tort) (3 – 4 questions)

Intentional Tort:
- Assault: a threat toward another person that places the person in
reasonable fear of harm or unwelcome contact. Assault does NOT require
actual physical contact - a verbal threat can be considered assault.
- Battery: actual contact - offensive touching without consent or lawful
justification. The contact can be harmful/cause injury or can just be offensive
to the person's dignity.
- False Imprisonment: restraint without a legal reason, preventing the ability
to move about freely (physical or chemical restraint).
Quasi-intentional tort:
- Invasion of privacy: unlawful intrusion into private affairs, possessions,
disclosure of private info
- Defamation of character: publication of false statements that causes injury
or damage to a person's character
Unintentional tort:
- Negligence: conduct that falls below the generally accepted standard of care
used by a reasonably prudent person
- Malpractice: when a professional fails to properly execute their duty to a
client.

Know the criteria necessary to establish nursing

malpractice (you will be given patient-nurse scenarios
will you need to identify the criteria listed below) (2 – 3
questions)That the nurse/physician/provider owed the patient a
duty/standard of care
2. That the duty or standard of care was breached/fell below the
standard of care
3. That the breach in the standard of care caused injury to the patient
(causation)
4. That the injury sustained caused damage (injury/harm)

Duty: professional nurse-patient relationship. The duty of a nurse is to

act as a reasonable nurse would act under the same or similar
circumstances when caring for patients

Breach: failure to use the degree of skill and care ordinarily used under
same or similar circumstances - fallen below standard of care

Causation: a breach in the standard of care caused injury to the

patient

Harm: injury caused damage

 Informed Consent – be familiar with general principles and the nurse’s role with
informed consent (1 - 2 questions)
 Informed Consent: Principles and Nursing Roles:
Informed consent: patient's agreement to receive medical care after
receiving full explanation of risks, benefits, alternatives, and consequences
of refusal - disclosed in language the patient can understand

Nursing roles: witness signature on informed consent form, make sure the
form is signed. NOT our role to explain procedure, risks/benefits, etc. That
is the provider's responsibility.

 Laws of reporting neglect/abuse – be familiar with general principles and the nurse’s
role with reporting (1-2 question)

Mandatory Reporting:
As a healthcare provider, you have a duty and responsibility to report
abuse or neglect of patients (children and elderly) if you have REASONABLE
SUSPICION to believe that patient is at risk of harm.
You also have a duty to report communicable diseases to the health
department.

 Reasons for involuntary admissions. (1-2 question)

Reasons: Court Ordered

- Dx w/ mental illness
- Clear and present danger to self
- Grave disability - can't take care of themselves
- Need for involuntary treatment - essential for health and safety
- Lack of capacity to consent/seek tx

 Be familiar with Terminology (2 – 3 Questions)

HIPAA Approximately
- Understand nursing’s role in maintaining patient privacy and confidentiality 8 – 10
- Use of social media questions

Do NOT use social media to post ANY patient information. No befriending a patient on social
media. This is a professional relationship
- Disposal of patient information

Make sure that any paper documents that are not part of the medical record are shredded after
use so that privacy of PHI is maintained

- Rules regarding disclosure of health care information

You can’t talk about patients outside of the hospital with anyone
Clinicians should only access the medical information that is needed for their job/clinical
experience. (minimum necessary information)We need patients to give permission before we
can give information to others on their behalf.
Keep medical records in a secure place-both paper & electronic.

- Without Authorization - To individual

- Treatment, payment, healthcare operations
- Informal permissions and emergency situations
- Public health activities
- Funeral homes
- Organ/tissue banks
- Victims of abuse, neglect, or domestic violence
- With Authorization - Any use not permitted by HIPAA
- Pre-employment physical or lab tests
- Psychotherapy notes
- Marketing purposes
- More than “minimum necessary”
- Patients’ confidentiality when giving/receiving report & in public places, on the
computer.
Not allowed to discuss in public places, needs to be protected.

- Be able to identify violations of HIPAA in a nurse-patient scenario

- Understand nursing’s role in maintaining patient privacy and confidentiality

Act of keeping information private or secret; in health care the nurse only shares information
about a patient with other nurses or health care providers who need to know private information
about a patient to provide care for him or her; information can only be shared with the patient’s
consent.
- Communicate orally in a way that others not involved in the patient’s care cannot
hear you
- Family requires a “code” if they call in to receive updates on medical condition

- Be able to identify HIPAA violations

- What type of penalties are associated with HIPAA violations?
Punish those who misuse patient information by imposing criminal & civil penalties

- How patients give consent for release of medical records

Patients are required to sign a statement that they were informed of and understand the privacy
practices

Care Delivery (Health Care Law – Standards of Practice /Nurse Practice Act) Approximately
6 questions
 Be familiar with state statutory issues in nursing practice regarding:
Legal Control Over Nursing Practice:
Nurse Practice Act—statute and rules governing nurses in your state
Board of Nursing—agency designated
to apply laws to individuals

 Licensure
 Purpose of NCLEX
State Laws: Licensure & NCLEX –
State laws:
Licensure - must complete approved RN program, state and Nat'l
background check, pass NCLEX - Renew license every 2 years, 30 CEs req.

Temp license good for 6 mo from date app submitted ($60), $150 fee for
initial licensure, reexamination = $60 $110 for renewal, lapsed license
must submit reactivation/reinstatement app, 4+ years lapse = refresher
course, permit to practice can be issued after graduating/after
application for/pending NCLEX - direct supervision, valid until results of
NCLEX

In order to be licensed, you must pass the NCLEX - purpose of NCLEX is to

standardize nursing knowledge across states - to assess a candidate's
ability to provide safe, evidence based, effective nursing care - protect
public

 Understand ‘Standards of Practice” and what they are (ex: Nursing Practice act, ANA
standards for nursing practice, Accrediting agencies polices/procedures, Institution
policy/procedures)
Nurse Practice Acts/ Standards of Practice:
NPA: Generally describes what nurses can do - scope of practice. More
specific list of what is prohibited. *PROTECTS THE PUBLIC
Describes how to get licensed, when and how to renew license, CE req.,
Board selection, grounds for discipline (revocation or suspension of
license), process for disciplinary actions/appeals

Standards of care: legal guidelines defining nursing practice - min

acceptable nursing care

Standards of practice: ANA

Describe a competent level of nursing care
- Assessment: collection of data relative to pt situation
- Diagnosis: analyze assessment data to determine actual or potential
dx/problems/issues
- Outcomes Id: Id expected outcomes for care plan individualized to pt or
situation
- Planning: develop plan/strategies to achieve expected outcomes
- Implementation: carry out identified plan - includes coordination of care
and teaching/education
- Evaluation: evaluate progress towards achieving goals and outcomes

Set by every state - state and federal laws that govern nurses - Joint
 Commission req. P&PsB

 Nursing Practice Act in New Mexico

 Be familiar with ways that a nurse can be admitted to the diversion program
NPA New Mexico Diversion Program:
Ways to be admitted into program:

- Voluntarily by requesting admission/reporting drug or ETOH problem

- Nurses who have had a complaint filed against them alleging
use/abuse of drugs or ETOH
- Request admission in lieu of formal board action against their license

 Legal responsibilities of a student nurse

Student Nurse – Legal Responsibilities:
Student nurses are legally responsible for their actions (as are instructor,
hospital, program, college)
Stay within scope of practice

Technology Approximately
5–6
 Be familiar positive outcomes that comes from Health Information questions
Technology
Positive outcomes from tech: improve quality, safety, efficiency
· Improves health provider's workflow
· Improves quality of healthcare/continuity of care
· Prevents medical errors
· Reduces healthcare costs
· Improves disease tracking

Reduced errors of omission, better access to info, better quality

documentation, reduced hospital costs, increased job satisfaction, compliance
w/ req. of accrediting agencies (TJC), common database.
 Know the difference between Health Information Technology and Health
Informatics
Health information technology: the application of information processing that
deals with storage, retrieval, sharing, and use of healthcare data, info, and
knowledge for communication and decision making.

Health informatics: a discipline in which health data are stored, analyzed, and
disseminated through the application of information and communication
technology.
 Identify and describe the 5 domains of informatics
5 Domains of Informatics:
Translational bioinformatics: the development of analytic and interpretive
methods to transform large amounts of biomedical and genomic data into
proactive, predictive, preventive, and participatory health that can be
disseminated to a variety of stakeholders

Clinical research informatics: focuses on the advancement of health

sciences through ethical use of informatics, including appropriate
collection and maintenance of deidentified patient data

Clinical informatics: the application of information and communication

technologies to healthcare delivery services focused on information used
in healthcare by clinicians like provider orders, digital imaging, and
documentation

Consumer health informatics: geared towards providing better healthcare

based on the patient's perspective

Public health informatics: the use of information, computer science and

technology to better the health of populations by developing tools and
technology focused on public health issues, like outbreak monitoring and
response

 What are clinical decision support systems?

Clinical Decision Support System:
Clinical Decision Support System: a computer program that aids and
supports clinical decision making.

Tools such as alerts, reminders, diagnostic support, drug interactions,

clinical guidelines are some examples of CDS

 Informatics Competencies for nursing graduates entering the workforce

QSEN informatics competencies for nursing graduates:
Know how to enter/record info in EHR
How to review information in EHR
Sim lab - EBP in action - use of electronic tools, clinical decision support
tools

 Be familiar with what “meaningful use” means in terms of informatics

 Meaningful Use:
Establishes criteria re technological use of the EHR according to federal
guidelines - ensures EHR technology is used in a meaningful way and that
HI is shared and exchanged to improve patient care.

5 pillars:
Improve quality, safety, and efficiency while reducing disparities
Engaging patients and families
Improving care coordination
Improve public health
Ensure privacy for PHI

 Please make sure to review terminology

Intro to Evidence Based Practice 9 – 11

questions
 Know the definition of evidence-based practice and be familiar with the model for
evidence based clinical decision making
Evidence-Based Practice:
EBP model:
· Evidence from research, evidence-based theories, clinical experts, and
opinion leaders
· Evidence from assessment of patient history and physical and available
healthcare resources
· Information about patient preferences and values
Clinical expertise

 Know the 7 steps of EBP, know their order and how to apply them
Seven steps of EBP:
· Cultivate a spirit of inquiry within an EBP culture and environment
· Ask a clinical question in PICOT format
· Search for the most relevant and best evidence
· Critically appraise the evidence you gather
· Integrate the best evidence with your clinical expertise and patient preferences
and values to make the best clinical decision
· Evaluate the outcomes of practice changes based on evidence
· Communicate the outcomes of EBP decision or changes

 Be familiar with the differences between Qualitative and Quantitative research.

Qualitative Research vs. Quantitative Research
Qualitative research answers questions that cannot be answered quantitatively
by using contextual, non-numeric data, like surveys and questionnaires, to take
into account the patient experience

Ex:
Ethnography
Phenomenology
Grounded theory
Case study

Quantitative research is the testing of a hypothesis through objective observation

and validation. It is precise, systematic, and focused on numerical data, statistical
analysis, and controls to minimize bias

Ex:
Randomized controlled double-blind studies
Cohort studies
Longitudinal studies
Case-controlled studies

 Be familiar with the different types of research (Box 5.3 in your Potter and Perry
Textbook)
Types of Research:
Exploratory: initial non-experimental study designed to develop/design a
hypothesis

Evaluation: form of quantitative research - study that tests how well something is
working - used to ID problems and opp for change

Descriptive: study that measures characteristics of people, situations, groups and

frequency in which certain events or characteristics occur

Historical: descriptive research designed to establish facts related to past events

Experimental: study in which investigator controls study variable and randomly

assigns subjects to diff test conditions - to test for variable

Correlational: non-experimental study - explores relationship among variables

without active intervention by researcher

 Be able to identify the components of a PICOT question

PICOT Question:
Components:
P: population
I: intervention/area of interest
C: comparison intervention/area of interest (*USUAL STANDARD OF CARE)
O: outcome
T: timeframe
 Ex:
Is an adult patient's (P) blood pressure more accurate (O) when measuring with
the patient's leg crossed (I) versus the patient's feet flat on the floor (C)?

For post-surgical patients(P), does the use of an incentive spirometer (I) decrease
the risk of developing pneumonia (O) versus regular patient repositioning (C)?

 Be familiar with the types of secondary literature: evidence summaries, systemic

reviews, meta-analysis and practice guidelines.
Secondary Literature:
Secondary literature summarizes findings from individual or multiple studies

Types:
· Evidence summaries: Literature that summarizes original research studies

· Systematic reviews: Provides a synopsis of quantitative evidence by gathering

evidence from several randomized controlled trials and summarizing the results
of the studies. Systematic reviews synthesize the results of many studies that are
then evaluated, and a conclusion is drawn about the effectiveness of the
treatment being studied

· Meta-analyses: Provides a synopsis of quantitative evidence by summarizing

evidence from multiple studies, focusing on combining the statistical results and
analyzing the evidence

· Practice guidelines: Designed to summarize research findings to advise

practitioners on the current standard of care. Guidelines should be based on
systematic reviews (top tier evidence) and use an evidence rating/grading
system.

 Please make sure to review terminology

Safety Overview 20 – 24 total

Types of Errors (9-10): be familiar with the following types, able to identify/assess and to look questions
at solutions:
 Errors:Treatment/diagnostic/prevention/communication
Safety:
Types of errors:
Treatment: Occur in the performance of an operation, procedure, or test, in
administering treatment, in dose or method of medication administration, or in
avoidable delay in treatment or delayed response to an abnormal test result
 Diagnostic: Delay in diagnosis, failure to implement indicated tests, use of
outdated tests, failure to act on results of monitoring or testing

Preventive: Occur when there are failures to provide preventive treatment and
lack of monitoring or follow-up treatment

Communication: Errors caused by communication failure due to lack of

communication or lack of clarity of communication

 Current strategies to minimize errors

Strategies to Minimize Error:
#1 way to reduce errors = forcing fxn and constraints - make it hard or impossible
to do the wrong thing

Take advantage of est. habits/patterns

Streamline processes to reduce confusion
Simplify processes to reduce complexity/risk of workarounds
Checklists
Standardize: decrease variation/easier to fix deficit
Reduce reliance on memory (slips and lapses) - errors of planning and execution -
CHECKLISTS!
Improve access to info (decision support systems)
Visual aids
Improve team fxn - sim situations
Redundancies - double-checks
Eliminate distracting enviro factors
Create systems better able to tolerate/respond to errors

 Errors: Near Miss/Adverse Event/Sentinel Event

Adverse event: an event that results in unintended harm to the patient by an act of
commission or omission (rather than the underlying disease/condition of the patient)

Near miss: an error of commission (did not provide care correctly) or omission (did
not provide care) that could have harmed the patient but did not cause serious harm
by chance

Sentinel Event: an unexpected occurrence involving death or serious physical or

psychological injury, or the risk thereof (includes loss of limb or function) - signal need
for investigation and response

 Characteristics of a root cause analysis (RC)

Root Cause Analysis Components:
The problem is defined
 Data is gathered
Root cause associated with problem is ID

Explore cause and effect relationship

Root cause: latent vulnerability in system that allows accident to occur

5 Why's: ID real root causes, not just sx of problem

- Ask why something happened and keep going at least 5x until you get to the
root cause

RCA: key components

Active leadership engagement & support
Non-punitive approach
Transparent risk-based prioritization
Timeliness
Effective team composition and pt engagement
Application of tools (triggering Qs, 5 rules of causation, action hierarchy)
Providing feedback and celebrating wins

Timeline: w/i 72 hours

Immediate actions taken to care for pt, make situation safe for others, sequester
equipment/preserve evidence
Risk mgt prioritization

Within 30-45 days:

Assemble RCA team, gather data/conduct interviews, develop causal statement,
ID solutions/corrective action

Implement, Measure, Feedback

 Blunt versus sharp errors

Blunt (latent) vs Sharp (active) errors:
Sharp/Active errors are those made by healthcare providers at the point of direct
patient care. Active errors have the potential to cause immediate harm.

Blunt/Latent errors are more organizational, systems-based errors caused by a

flaw on the overall healthcare delivery system. Latent failures may not lead to an
accident immediately, but identify a situation that could potentially lead to an
error

Safety Cultures (2-3 questions):

-Know characteristics & how to implement in an institution.
 Characteristics of Cultures of Safety
 Cultures of Safety:
A culture of safety focuses more on the role of safety in patient outcomes by
investigating what went wrong and why, rather than just identifying and
punishing the offending provider.
A culture of safety includes individual and group values, attitudes, perceptions,
competencies, and patterns of behavior that determine an organization's
commitment to health and safety management.

In a culture of safety, the focus is on teamwork to accomplish the goal of safe,

quality care - when an error occurs, the focus is on what went wrong, rather than
blaming or punishing the person who made the error
Encourages accountability and the reporting of errors without fear of punishment
to improve the overall system

There are (7) key aspects to a culture of safety: Leadership, teamwork, evidence-
based practice, communication, learning, a just culture, and patient-centered
care

 High Reliability Organizations

High Reliability Organizations characteristics:
Manage work that involves hazardous environments - consequences of errors is
high, but occurrence of error is low

Transparency: preoccupation w/ failure - focused on predicting/eliminating errors

rather than reacting to them - view near miss events as opportunities to improve
current systems

Communication: deference to expertise - defer to the person with the most

knowledge, regardless of position/rank - deemphasizes hierarchy

Improvement models: reluctance to simplify - accept complexity of work and do

not accept simple solutions to complex problems

Continuous learning: sensitivity to operations - situational awareness that ID

process anomalies to avoid error

Accountability: commitment to reliance - focus on ability to quickly contain errors

and return to function despite setbacks

Share power and standardize communication - value of safety

 Open systems
 Just Culture elements
Just Culture Elements:
Being able to report errors without punishment
 Still holds person accountable for actions, but they are NOT punished for flaws in
the system
Promotes transparency
Balance b/w learning from mistakes and need to implement corrective or
disciplinary action

Considers/differentiates b/w:
Human error: inadvertent action (slip or lapse)

At risk behavior: choice that increases risk when risk not recognized or mistakenly
believed to be justified

Reckless behavior: conscious disregard for substantial risks

Identify the major threats to safety for each of the Developmental stages. Also, identify
interventions to promote safety AND prevent safety threats/risks ( 2- 3 questions)

Identify Individual, Home Environment AND Health Care Agency Risk Factors that pose
threats to Safety (2– 4 questions)

Information from IHI modules (approximately 4 - 5 questions)

 Be familiar with the following content from the IHI modules
IHI Safety Culture Elements:
Accountability, not punishment
Errors identified and mitigated before they cause harm
Strong feedback loops to enable learning from past events/alter care processes to
prevent recurrence

 Human Factor Principles in health care settings

Human Factors Principles:
Understanding how people perform in different circumstances

Human Factors: addresses the interrelationship of people, technology, and the

environment they are working in.

Human factors consider the ability or inability to multi-task. Considerations

include external environment, management, physical environment, human-
system interfaces, organizational culture, and the nature of work being done.

 Importance of check lists

Importance of Checklists:
Reduces reliance on memory
Reduces errors of planning and execution

Should be used when there are multiple step processes to make sure all have
 been completed

 The use of redundancies (double checks). When should they be used?

When a secondary system is needed in the event a first system fails. Within a situation where a
failure in the first step can result in serious harm. Although not every process in health care
requires a redundancy, it is important to have one when a primary system can fail and such
failure would result in harm.
 Culture of safety (what is it and what are the main characteristics)
Cultures of Safety:
A culture of safety focuses more on the role of safety in patient outcomes by
investigating what went wrong and why, rather than just identifying and
punishing the offending provider.
A culture of safety includes individual and group values, attitudes, perceptions,
competencies, and patterns of behavior that determine an organization's
commitment to health and safety management.

In a culture of safety, the focus is on teamwork to accomplish the goal of safe,

quality care - when an error occurs, the focus is on what went wrong, rather than
blaming or punishing the person who made the error
Encourages accountability and the reporting of errors without fear of punishment
to improve the overall system

There are (7) key aspects to a culture of safety: Leadership, teamwork, evidence-
based practice, communication, learning, a just culture, and patient-centered
care

 Psychological safety
Psychological Safety:
Feeling secure and capable of adapting to change, feeling free to focus on
collective goals and problems rather than on self-protection

Knowing no one will be humiliated or punished for speaking up.

 Be familiar with the differences between Slips, Lapses, Mistakes and

Violations

National Patient Safety Goals (NPSGs) (approximately 3 – 4 questions)

 Understand the purpose/need for national patient safety goals
National Patient Safety Goals;
Purpose: established to help accredited organizations address specific areas of
concern in regard to patient safety
To reduce errors in healthcare/improve quality and safety of care provided

 Review the current goals and focus on basic interventions to meet the
following goals
- Improve the accuracy of patient identification
- Improve the effectiveness of communication among caregivers
- Reduce the risk of health care-associated infections
NPSG – Goals and interventions:
 Improve accuracy of pt identification
- 2 patient identifiers
Improve communication
- Report critical results of tests and diagnostic procedures on a timely basis

Reducing risk of HAIs

- Comply with either the current CDC hand hygiene guidelines or the current WHO
hand hygiene gudelines

Compare/contrast nursing center (long term care facility) NPSG with

hospital goals—focus on these two facilities.
NPSG – Goals for Long term vs Hospital:
Long term care:
Pt id
Medication safety
- anticoagulant tx
- comm pt med info
Reduce HAIs, falls, pressure ulcers
Hospital:
Pt id
Communication
Med safety
- labeling
- comm pt med info
Clinical alarm safety
Reduce HAIs, suicide risk
Increase healthcare equity
Wrong site surgery
- marking procedure site
- time out

QSEN (approximately 6 questions)

 Be able to describe the six QSEN competencies
[Link]-centered care: Recognize the patient or designee as the source of control and full
partner in providing compassionate and coordinated care based on respect for patient’s
preferences, values, and needs
2. Teamwork and collaboration: Function effectively within nursing and inter-professional teams,
fostering open communication, mutual respect, and shared decision-making to achieve quality
patient care
3. Evidence-based practice: Integrate best current evidence with clinical expertise and
patient/family preferences and values for delivery of optimal health care
4. Quality improvement: Use data to monitor the outcomes of care processes and use
improvement methods to design and test changes to continuously improve the quality and
safety of health care systems
5. Safety: Minimize risk of harm to patients and providers through both system effectiveness
and individual performance
6. Informatics: Use information and technology to communicate, manage knowledge,mitigate
error, and support decision making

 Be familiar with the 3 elements included in QSEN competencies -(KSAs) and why they
are important
QSEN – KSAs:
Knowledge
Skills
Attitudes

Necessary to continuously improve the quality and safety of the healthcare

systems within which they work.

[Link]

 You will be given several patient-nurse scenarios and you will need to be able to
identify which QSEN competency the nurse is demonstrating (approximately 4
questions)

Be familiar with Terminology for Safety