IHI PS 102
The physician forgets to remove the catheter when it's no longer needed.
Lapse
A 52-year-old man with a history of ulcers and bleeding in his gastrointestinal tract as a result of taking ibuprofen visits his primary care doctor with a running injury.After examining him, the physician tries to prescribe ibuprofen to treat his condition. The medication order entry system issues an alert — the 25th one that day — and the physician ignores the alert without reviewing the patient's medical record, thinking the alert is likely to be another "false alarm." Behind on his schedule, he chooses to override the alert and prescribe the ibuprofen. After taking the medication, the patient develops bleeding in his gastrointestinal tract and has to be admitted to the hospital. What type of unsafe act, if any, is represented in this case example?
Violation
The physician skips hand-washing because she's in a hurry and just washed her hands in the previous patient visit.
Violation
A physician attends a luncheon at a restaurant near her work, and consumes several alcoholic beverages. Once at work, she inadvertently drops equipment on the floor several times during a procedure, presenting an infection control risk. She yells at the staff members who remove the contaminated items. Should she be held accountable for her actions?
Yes
What intervention helped prove that catheter-associated bloodstream infections (CLABSIs) were preventable consequences of care?
A checklist of evidence-based practices applied consistently and collectively every time a catheter is used
According to James Reason, by definition an "unsafe act" always includes:
A potential hazard
Implementing a "systems approach" to addressing medical error includes which of the following?
All of the above
Which of the following factors makes health care dangerous to patients and providers?
All of the above
Why do some patient safety leaders believe the definition of harm should be broader than the definition in the IHI Global Trigger Tool?
Because health care systems should work to prevent more types of harm than the current definition includes
The Swiss cheese model of accident causation illustrates what important concept in patient safety?
Both latent unsafe conditions and active failures (unsafe acts) contribute to harm AND harm results when the layers of defense in a system fail to prevent a hazard from reaching a patient.
Referring to the video on the previous page, which of the following factors do you think contributed to the Tenerife plane crash?
- Foggy weather that limited visibility -Stress and distraction on the part of the pilot - Time pressure due to crew duty hours - Language differences -Miscommunication between the two planes and the control tower -Problems with the radio transmission -A hierarchical culture that limited the junior crew's willingness to speak up
Referring to the video on the previous page, which of the following factors do you think did not contributed to the Tenerife plane crash?
- Incompetent staff - Mechanical problems
The term "medical error" is slightly misleading because the patterns of errors that occur in health care are no different from those that occur in any other setting when we are distracted, in a hurry, or just plain forgetful. Consider the following scenario: A nurse, Anila, oversleeps and is running late to work. As she rushes through her morning routine, she forgets she promised to call her mother to confirm plans for later in the day.Anila makes it out the door in record time and decides to drive toward the highway, thinking it will be faster than her usual route to the hospital — only to find traffic is backed up for miles!At last, Anila makes it to work. As she hurries inside, she finally remembers to call her mom. But in her hurry, she accidentally calls her boyfriend instead. "Three errors and I haven't even seen a patient yet," she thinks. Which type(s) of error did Anila make? (Select all that apply.)
- Slip - Lapse - Mistake
Which of the following would be an effective solution to help prevent the Tenerife disaster from happening again?
- Train people about safety culture to help them speak up in a hierarchical system. - Standardize communication about clearance for take off.
"Latent errors" are best defined as:
Defects in the design and organization of processes and systems.
Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for "units"), and it looks more like an extra zero. As a result, the pharmacist dispenses an insulin dose that's ten times stronger than the patient needs. To prevent this problem from happening again, which of the following would be the best course of action?
Develop a system that prevents messy handwriting from causing miscommunication that leads to error.
A surgeon mistakenly operates on the wrong foot, and the patient has to undergo a second surgery. Would the IHI Global Trigger Tool recognize the case as harm?
Harm
What is one reason that patient safety has shifted to work on reducing harm in addition to preventing errors?
Harm is more preventable than providers once thought.
Which of the following is the most significant advantage of shifting to a systems view of safety within health care?
It allows us to change the conditions under which humans work.
At University Hospital, the rate of Clostridium Difficile colitis has doubled during the past year. After reviewing the data, the hospital's senior leaders conclude that this is due to poor hand hygiene on the part of the staff, even though they have a clear hand washing policy in place and don't believe most staff are intentionally disregarding the policy. They decide to start a hand washing campaign and post signs all over the hospital reminding providers to wash their hands. What type of error is this intervention best designed to address?
Lapse
Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for "units"), and it looks more like an extra zero. As a result, the pharmacist dispenses an insulin dose that's ten times stronger than the patient needs. Which of the following is a latent unsafe condition in the system that contributes to the resident's error?
Long work schedule
A 28-year-old, obese woman goes to a clinic complaining of severe calf pain that keeps getting worse. She tells her primary care physician that she thinks the pain is due to the new shoes she bought and her new commitment to walking and exercising more. She has no history of leg trauma, and her only medication is a birth control pill.After examining her, the physician does not see anything unusual, and prescribes ibuprofen and muscle relaxants. A week later, the patient has a heart attack and is unable to be resuscitated. A post-mortem examination reveals a massive blockage in the artery that passes through her lung. What type of unsafe act, if any, does this case demonstrate?
Mistake
Subha, a nurse practitioner, is seeing Mr. Dooley in clinic. Mr. Dooley is a 55-year-old man who presents with a high fasting blood glucose. Subha diagnoses him with Type II diabetes. Several years later, however, an endocrinologist performs some additional testing and finds that Mr. Dooley actually has adult-onset Type I diabetes. Which of the following types of errors does this story best demonstrate?
Mistake
The resident physician does not have sufficient training to perform a subclavian placement for the line.
Mistake
In the middle of a long and busy day, a dedicated obstetrics nurse is providing medical care and emotional support to a 16-year-old woman having her first baby. Thinking she is giving the patient an IV antibiotic, she instead accidentally administers a local anesthetic, which is sitting on the same counter, housed in similar packaging. The patient dies within minutes from an adverse reaction. Should the nurse be punished for this error?
No
A doctor tells a patient that she is HIV-positive because of a false lab result, but corrects the mistake before there is any impact to her care. Would the IHI Global Trigger Tool recognize the case as harm?
No Harm
A nurse administers too much of a sedative because he misinterprets an order, but the patient doesn't feel different. Would the IHI Global Trigger Tool recognize the case as harm?
No Harm
A patient's test result shows she may have a blood clot, but the primary care clinic doesn't order the next test to confirm. In the meantime, the blood clot causes the patient to have a stroke. Would the IHI Global Trigger Tool recognize the case as harm?
No Harm
Which of the following is included in the IHI Global Trigger Tool definition of harm?
Physical injury caused by medical care that triggers additional care
The nurse accidentally brushes the sterile tube against a non-sterile surface.
Slip
Two women — one named Camilla Tyler, the other named Camilla Taylor — arrive at a particularly busy emergency department at about the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an antibiotic. The doctor orders the medications, but mixes up the patients when filling out the order sheets. The pharmacist dispenses the medications as ordered, and the nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor. What is one of the latent errors in this scenario?
The forms are completed by hand at the same time for different patients.
Two women — one named Camilla Tyler, the other named Camilla Taylor — arrive at a particularly busy emergency department at about the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an antibiotic. The doctor orders the medications, but mixes up the patients when filling out the order sheets. The pharmacist dispenses the medications as ordered, and the nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor. What is the active error in this scenario?
The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.
