PS 101: Introduction to Patient Safety

A brain surgeon was about to perform a difficult procedure on a high-risk patient. Several of the surgical team members had just met for the first time.The surgeon walked into the room and announced, "Good morning, team. This is a difficult case, and I'm human like everyone in this room. Please speak up if you see me about to make a mistake or have a suggestion to help."She then went around the room and introduced herself to everyone by her first name. Is the surgeon showing good leadership? Yes or No

Yes

On a hectic day at work, imagine you mistakenly hook up a patient's oxygen supply to compressed room air instead of forced oxygen. You realize and correct the mistake before any harm comes to the patient. Should you report the error? Yes or No

Yes

The term "normalized deviance" refers to: A. Acceptance of events that are initially allowed because no catastrophic harm appears to result. B. The increase in disturbing song lyrics in modern music. C. Innovation based on observing positive outliers in a production process. D. The standard deviation of a variable in a "bell curve" distribution.

A. Acceptance of events that are initially allowed because no catastrophic harm appears to result.

You have a safety concern and feel that you must escalate the problem. In this context, "escalation" means: A. Communicating the problem, including when and where it is occurring, to the person who has the span of authority to fix system flaws. B. Making an anonymous report to the CEO's office. C. Getting many workers to report the same problem to make sure it's real. D. Temporarily making the problem worse, which then results in attention being paid to it

A. Communicating the problem, including when and where it is occurring, to the person who has the span of authority to fix system flaws.

"Patient safety" means: A.Eliminating errors and adverse effects to patients associated with health care B. Eliminating waste in health care services C. Eliminating health inequities in populations D. All of the above

A. Eliminating errors and adverse effects to patients associated with health care

You're an administrator at a hospital in a fast-growing suburb. Your hospital has hired three new orthopedic surgeons, including a new chief. These new hires are likely to triple the number of knee replacements done in your hospital. Currently, this procedure is done infrequently, and each time it feels a bit chaotic. As you consider the number of individuals with specialized skills required to execute a safe, effective knee replacement (nurses, surgeons, and anesthesiologists, as well as pre-operative, operating room, and post-operative staff), you realize that this process has the properties of a complex system.A few weeks after the new chief of orthopedic surgery comes on board, she has a moment of inspiration and sketches out a new, radically different way for patients to "flow" through the pre-operative, intra-operative, and post-operative phases. She sends you an email saying that she wants you to meet with her Monday morning to begin implementing it. Which of the following should you keep in mind as your hospital redesigns the way it handles knee replacements? A. How system components are integrated with one another is as important as how well they function independently. B. To ensure buy-in, the leader of the design process should be as high up in the organizational hierarchy as possible. C. Planning by a multidisciplinary team should allow for the development of an excellent, high-functioning system on the first try. D. Planning a new complex system for health care delivery has little in common with planning an industrial production process

A. How system components are integrated with one another is as important as how well they function independently.

At the large multi-specialty clinic in which you work, there have been two near misses and one medical error because various clinicians did not follow up on patient results. Different caregivers were involved each time. When asked why they failed to follow up, each caregiver said he or she forgot. Based on what you know, how would you classify the caregivers' behavior? A. Human error B. At-risk behavior C. Reckless behavior D. None of the above

A. Human error

Why is psychological safety a crucial component of a culture of safety? A. It allows people to learn from mistakes and near-misses, reducing the chances of further errors. B. Without it, patients will not follow their doctors' advice. C. It allows people to remove unsafe members of the team quickly. D. Without it, people won't be interested in improvement work.

A. It allows people to learn from mistakes and near-misses, reducing the chances of further errors.

You meet with the nurse administrator responsible for improvement when issues in the process of care are identified by those on the wards. She listens carefully to your concern, but in the end says she can only try to help improve nursing issues, and not those that extend to pharmacy or transport. The primary reason your meeting is unlikely to lead to an adequate solution is: A. The nurse administrator did not have the appropriate span of responsibility to engage the system components needed to solve the problem. B. No one is identified as responsible for improvement when abnormalities in the process of care are identified. C. The responsible individual belittled the nurse reporting the problem. D. Since things have been going along without a serious adverse event for several months, it appears that the current work-around is effective.

A. The nurse administrator did not have the appropriate span of responsibility to engage the system components needed to solve the problem.

Since the publication of To Err Is Human in 1999, the health care industry overall has seen which of the following improvements? A. Wider awareness that preventable errors are a problem B. Wider recognition that medical errors are most often attributable to individual performance C. Stronger repercussions for providers who commit preventable medical errors D. A 75 percent reduction in preventable medical errors

A. Wider awareness that preventable errors are a problem

Referring to the video on the previous page, who, in your opinion, is to blame for Hannah's fall? Check all that apply. (This quiz is not required to complete the course.) Tom Daria and Deepa Joe Rachel Hannah All of these people None of these people

All of these people None of these people

A medical unit in a hospital is in the midst of hiring some new physicians. During an orientation for new employees, a senior leader stands up and says, "We expect that the same rules apply to everyone on the unit, regardless of position." Which aspect of a culture of safety does this unit seem to value? A. Psychological safety B . Accountability C. Negotiation D. None of these

B . Accountability

According to WHO, in developed countries worldwide, what is the approximate likelihood that a hospitalized patient will be harmed while receiving care? A. 5% B. 10% C. 33% D. 66%

B. 10%

James is a first-year surgery resident on his first pediatric rotation. His attending (supervising physician) asks him to start intravenous (IV) replacement fluids on a two-year-old boy who is having vomiting and diarrhea. Having trouble remembering the guidelines for calculating fluid replacement rates for very small children, James asks Maria, a nurse on the unit. Maria responds, "You're the doctor. It's your job to decide this." James picks a rate that is much too high, putting the child into fluid overload. To prevent this type of error from recurring in this unit, which of the following is MOST important? A. More severe, well-publicized consequences for providers who are reckless B. An improved culture of safety and teamwork C. Closer supervision of residents, especially in the first year D. Clear medical guidelines for fluid replacement in patients of all ages

B. An improved culture of safety and teamwork

Which of these is a behavior providers should adopt to improve patient safety? A. Obey your superiors without question. B. Follow written safety protocols, even if they slow you down. C. Develop ways to work around broken systems. D. Ignore patients' individual preferences when they disagree with "best practice."

B. Follow written safety protocols, even if they slow you down.

Safety has been called a "dynamic non-event" because when humans are in a potentially hazardous environment: A. There is generally a high prevalence of "near misses." B. It takes significant work to ensure nothing bad happens. C. It requires the same kind of thinking that causes problems to set them right. D. It is natural to establish and follow safe practices.

B. It takes significant work to ensure nothing bad happens.

Janet is especially busy because one of her colleagues called out sick, and she needs to collect blood samples for four patients. She collects one sample, and before she gets a chance to label it, another patient in an emergency situation needs her help. She leaves the unlabeled specimen on the nurses' station for a moment. When Janet returns, there is a second unlabeled vial of blood at the nurses' station. She realizes another nurse was obtaining blood samples and was also called away. Neither nurse knows which vial belongs to which patient. What about this scenario seems to make an adverse event likely to occur? (Choose all that apply.) A. Janet is not trying hard enough at her job. B. Janet is juggling multiple tasks at once. C. Janet was interrupted in the middle of a task with inherent room for error. D. There are not enough staff members to keep up with the demands of care.

B. Janet is juggling multiple tasks at once. C. Janet was interrupted in the middle of a task with inherent room for error. D. There are not enough staff members to keep up with the demands of care.

At the large multi-specialty clinic in which you work, there have been two near misses and one medical error because various clinicians did not follow up on patient results. Different caregivers were involved each time. After the second near miss, the physician involved was asked to leave the clinic. This appears to be an example of which of the following? A. Just culture B. Unfair attribution of blame C. Reckless behavior D. Both just culture AND reckless behavior

B. Unfair attribution of blame

Approximately what percentage of US adults have experienced a medical error in their own or a family member's care at some point in their life? A. 1 percent B. 5 percent C. 33 percent D. 66 percent

C. 33 percent

For which of the above categories do you think Marx recommended disciplinary action? A. Human error B. At-risk behavior C. Reckless behavior D. None of the above

C. Reckless behavior

A patient is scheduled for surgery on her left leg. Initially, an intern prepares the patient by marking the correct surgical site on the dressing on the leg. The intern's teammate removes the dressing, but addresses the problem by marking the surgical site on the patient's skin. However, he uses a water-soluble marker. The ink becomes smeared and illegible. The attending surgeon is new and not familiar with the hospital's marking procedures. Meanwhile, the nurses helping with the surgery are busy preparing the patient and the operating room. Generally, the operating room schedule is tight, and everyone is in a hurry to move the surgery forward. What type of adverse event in particular is more likely to occur because of the system failures in this scenario? A. Improper anesthesia dosing B. Retained foreign body after surgery C. Wrong site surgery D. None of the above

C. Wrong site surgery

James is a first-year surgery resident on his first pediatric rotation. His attending (supervising physician) asks him to start intravenous (IV) replacement fluids on a two-year-old boy who is having vomiting and diarrhea. Having trouble remembering the guidelines for calculating fluid replacement rates for very small children, James asks Maria, a nurse on the unit. Maria responds, "You're the doctor. It's your job to decide this." James picks a rate that is much too high, putting the child into fluid overload. Who is likely to be negatively affected by this medical error? A. The patient and his family B. James (the first-year surgery resident) C. Maria (the nurse on the unit) D. All of the above

D. All of the above

Which of the following might be an appropriate system-level response to a "weak signal"? A. Changing the scheduling of shifts to prevent excessive fatigue among caregivers. B. Having a different system for medication storage and dispensing on each nursing unit, so look-alike medications are not placed next to each other. C. Sending an email reminding nurses to be more careful when taking medications from the drawer. D. Both changing the scheduling of shifts AND having a different system for medication storage and dispensing on each nursing unit

D. Both changing the scheduling of shifts AND having a different system for medication storage and dispensing on each nursing unit

What is most likely to happen if a health system punishes an individual for an unintended error that was the result of a systems problem? A. Staff may be less likely to talk openly about and learn from errors. B. Staff will be more careful and errors will decrease. C. The response will weaken the safety culture. D. Both staff may be less likely to talk openly about and learn from errors AND the response will weaken the safety culture

D. Both staff may be less likely to talk openly about and learn from errors AND the response will weaken the safety culture

One hospital CEO insists on including performance data in the hospital's annual report. "We do very well on most measures, except for one or two, but we put those in anyway," she says. "We want to hold ourselves accountable." Does this practice demonstrate effective or ineffective leadership? A. Ineffective leadership: Because results are an important indication of leadership, publicly sharing poor results is an unwise practice. B. Ineffective leadership: Leaders are people who have followers, and sharing poor results might cause the leader to lose some followers. C. Effective leadership: It is good to share results in the annual report, but the leadership would be even more effective if it shared only the strongest results. D. Effective leadership: Being transparent, even about poor results, is a mark of a good leader.

D. Effective leadership: Being transparent, even about poor results, is a mark of a good leader.

At the large multi-specialty clinic in which you work, there have been two near misses and one medical error because various clinicians did not follow up on patient results. Different caregivers were involved each time. After the second near miss, the physician involved was asked to leave the clinic. A nurse who realized that his colleagues weren't consistently following up on patient results reported the problem to the clinic leadership right away. Which response would be most consistent with a culture of safety? A. Transferring the nurse to another clinic B. Thanking the nurse and asking him to keep quiet about it C. Placing the item on the agenda for the leadership meeting next year D. Investigating the problem and seeking systems solutions

D. Investigating the problem and seeking systems solutions

Which of the following is typically true of "weak signals"? A. They are uncommon. B. They should only be called out by specifically designated individuals within a health care organization. C. They usually result in harm to caregivers or patients. D. They can combine with other human or environmental factors to result in catastrophe.

D. They can combine with other human or environmental factors to result in catastrophe.

How many new drugs does the FDA's Center for Drug Evaluation and Research approve every year? A. Less than 10 B. 10 to 20 C. More than 20

More than 20