Unit 6.3: Patient Safety and Risk Management

• Topic 01

  NHS Patient Safety Framework and Just Culture

  51 questions
• Topic 02

  Incident Investigation and Root Cause Analysis

  45 questions
• Topic 03

  Falls Prevention and Pressure Ulcer Prevention Bundles

  45 questions
• Topic 04

  VTE Risk Assessment and Prophylaxis

  45 questions

A few questions from this unit, with the answer and a full explanation. The complete bank is available when you start practising.

1. A trust's Patient Safety Incident Response Plan (PSIRP) specifies that medication errors involving high-alert drugs will receive a proportionate learning response rather than a full Serious Incident investigation, even when harm occurs. A nurse questions whether this is appropriate. Which of the following statements MOST accurately addresses the nurse's concern?

   • A
     Under PSIRF, organisations have discretion to calibrate their investigation response to maximise learning; a proportionate response for certain harm categories is permitted provided the rationale is documented in the PSIRP
     Correct answer
   • B
     A proportionate response is only permitted if the incident is a near miss; any harm requires a full investigation under PSIRF
   • C
     The nurse is correct to be concerned — PSIRF specifically prohibits reduced investigation for incidents involving high-alert drugs
   • D
     The trust is in breach of PSIRF because all medication errors causing harm must receive a full Serious Incident investigation
   Explanation

   PSIRF explicitly allows organisations to move away from a one-size-fits-all investigation model. Trusts develop a Patient Safety Incident Response Plan that identifies categories of incidents and the proportionate investigation response for each, based on learning potential and risk level rather than solely on harm level. The key requirement is that the rationale is documented and the plan is approved. Requiring a full SI investigation for every medication error involving high-alert drugs — regardless of context — would be contrary to PSIRF's proportionality principle.

2. An investigation into a ward drug error identifies that the nurse involved had been on duty for 13.5 hours, had skipped their break, was managing 14 patients, and was interrupted six times during the medication round. The RCA team recommends 'staff should be more vigilant during medication rounds.' Why is this recommendation inadequate from a human factors perspective?

   • A
     The recommendation is inadequate because it should require the nurse to use SBAR before each medication round
   • B
     The recommendation targets individual behaviour rather than the system conditions — fatigue, staffing ratio, break deprivation, and interruptions — that predictably increase error rates
     Correct answer
   • C
     The recommendation is adequate but should be supplemented by additional medication training for the nurse
   • D
     The recommendation is inadequate because the RCA should have been conducted by an external team to avoid bias
   Explanation

   Human factors science identifies that system conditions — fatigue, high workload, interrupted processes, missed breaks — predictably degrade human performance regardless of individual vigilance. Recommending 'more vigilance' does not address any of these system conditions. It places responsibility back on the individual without changing the environment that made the error likely. Effective human factors recommendations address the system: reducing interruptions, managing workload, ensuring breaks.

3. Which inquiry directly led to the creation of the Freedom to Speak Up Guardian role in NHS trusts?

   • A
     The Bristol Royal Infirmary Inquiry (Kennedy Report, 2001)
   • B
     The Morecambe Bay Investigation (Kirkup Report, 2015)
   • C
     The Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis Report, 2013)
     Correct answer
   • D
     The Ockenden Review of maternity services at Shrewsbury and Telford (2022)
   Explanation

   The Francis Report (2013), which investigated systemic patient harm at Mid Staffordshire NHS Foundation Trust, identified a culture of not speaking up as a root cause of the failures. This directly led to the mandating of the Freedom to Speak Up Guardian role in every NHS trust. While other inquiries also identified concerns about speaking up, the Francis Report is the direct precursor to the FTSU Guardian role.