ASHRM Certified Professional in Health Care Risk Management (CPHRM) CPHRM Question # 13 Topic 2 Discussion
CPHRM Exam Topic 2 Question 13 Discussion:
Question #: 13
Topic #: 2
A hospital uses the same labels for all prescriptions, but they don’t fit on small containers, so employees must cut/paste labels in a special way. This is an example of:
In Lean terms,extra processingis work that does not add value from the patient’s perspective and often introduces defect risk. Cutting and reformatting labels is a classic extra-processing waste: it consumes time, creates variability, and increases the likelihood of mislabeling—one of the most serious medication safety hazards. Risk management objectives prioritize eliminating rework and standardizing the labeling process through right-sized labels, standardized print templates by container type, barcode integration, and human factors design (font size, tall-man lettering where appropriate). Removing extra processing improves efficiency and reduces cognitive load and workaround culture—both strongly associated with error. Operationally, this is a system design failure: staff are compensating for poor equipment/process fit. Fixing the system reduces the chance of a high-severity adverse event and strengthens defensibility by demonstrating proactive hazard elimination.
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