Certified Professional in Patient Safety (CPPS) Practice Exam

In the case of a medication error, what should be considered before holding the nurse personally accountable using James Reason's unsafe acts algorithm?

1. Perform the substitution test with three other nurses

2. Have the chief nursing officer interview with the nurse

3. Hold a root cause analysis

4. Ask other nurses if the staff nurse is trustworthy

The correct answer is: Perform the substitution test with three other nurses

In the context of evaluating a medication error using James Reason's unsafe acts algorithm, it is essential to consider how systematic factors and individual actions contribute to the error. The substitution test involves analyzing the scenario by substituting the nurse in question with other nurses to determine if similar errors would occur under the same conditions. This approach helps to identify whether the error was due to individual failings or systemic issues like workload, communication, or environmental factors. By performing the substitution test, it becomes easier to assess whether the error could happen to any nurse in that given situation, thereby ensuring that accountability is applied fairly and justly. This method allows for a more comprehensive understanding of the factors leading to the medication error, leading to improved patient safety practices rather than assigning blame solely based on the error. Root cause analysis is an important tool in understanding systemic issues, and interviews can help gather valuable insights, but the substitution test specifically targets the evaluation of individual nurse performance in a more standardized way. Thus, using this approach reinforces the importance of addressing both human and systemic factors in medication safety.