PS103, PS104, and PS102 - Reviewer

One reason it's critical for caregivers to improve their teams' effectiveness is: a) Effective teams reduce the risk of errors by providing a "safety net" for individual caregivers. b) Effective teams limit the number of caregivers patients have to speak with, reducing confusion among patients and families. c) Teams rely less on technology and more on human capabilities, thus leading to better care. d) All of the above

a) Effective teams reduce the risk of errors by providing a "safety net" for individual caregivers. Effective teams — teams whose members communicate often and reciprocally — act as a kind of "safety net" that can help prevent errors resulting from one member's fatigue or distraction, for instance. Effective teams may still use technology often, and it's likely that patients and families will encounter many members of the team.

Promoting teamwork and effective communication may have mitigated this event by: a) Ensuring that the off-going nurse communicated with the oncoming nurse about the condition of the pump. b) Providing Karen with additional support or less stressful duties since she was fatigued from the unusual schedule. c) There was no need for additional communication, as the computer on the unit housed all of the information needed to provide safe care. d) a and b

Answer: D. Teamwork and communication can help improve the accuracy of patient handoffs and also provide support and backup for individuals when they are not functioning at their best.

Redesign the crash cart or supply room to keep easily confused drugs apart. a) Strong b) Intermediate c) Weak

a) Strong Changing the physical environment in which people work has a longer-lasting impact than giving instructions to one group of staff members.

In Margaret's case, Peter, Amy, Jorge, and Teddy came to work planning to do a good job. They didn't intend for Margaret to die, and neither did anyone else in the hospital. Each of these individuals was known as a smart, well-trained person. But somehow, things went horribly wrong. Would an RCA be useful in this case? a) Yes b) No

a) Yes Yes. In this case, a tragic event happened even though everyone involved in Margaret's care was trying to do the right thing. In this situation, a series of factors contributed to Margaret's death. Consequently, a retrospective, systematic analysis of the event would be warranted to help identify the causes that could be addressed.

Root cause analyses can be useful in health care because: a) They help to assign blame. b) They help to identify system failures that can be corrected. c) They are often quick and simple to perform.

b) They help to identify system failures that can be corrected. Root cause analyses are systematic approaches to understanding an error (or a near miss), with the hopes of identifying systems failures that can be addressed. They are not used to assign blame, nor are they necessarily quick. They are retrospective, occurring only after an error has happened.

Write a new hospital policy about patient transport. a) Strong b) Intermediate c) Weak

c) Weak Policies don't usually change behavior on their own and can be difficult to enforce.

Train staff in IV pump use. a) Strong b) Intermediate c) Weak

c) Weak Training, while beneficial, only impacts staff members who participate. People can also forget their training and revert back to old ways of doing things, so as a recommended action, this may be a bit weak.

You visit the local convenience store looking for a refreshing drink on a pleasant day. You know that you want a new type of cola beverage you've heard advertised on the radio, and reach into the refrigerator for what you think is the caffeine-free version of that cola. After you pay, pop the can, and begin drinking, you find that you purchased the sugar-free version instead (whoops!). What most likely contributed to this error? a) Look-alike cans/labels b) The ad on the radio c) The cost of the beverage d) The weather outside

a) Look-alike cans/labels Look-alikes, such as the case of the twin girls mentioned in this lesson, can contribute to error. In the case of the cola beverage, the two cans are probably the same shape with similar labels. None of the other factors are likely to have contributed to this error.

A vascular surgeon was doing a new, complicated procedure on a very high-risk patient in an unfamiliar setting. The procedure involved the coordinated efforts of several individuals, many of whom didn't know one another. The surgeon walked into the room and announced, "I have no pride invested in this procedure; I just want us to get it right. If you see anything that is helpful or see me getting off in the weeds, please speak up." He then went around the room and introduced himself to everyone by his first name. Is the surgeon showing good leadership? a) Yes b) No

a) Yes By introducing himself, encouraging participation, and valuing everyone's role, the surgeon creates a collaborative, open environment where people can participate and speak up easily. This allows the group to navigate problems, anticipate issues, and respond effectively to the ever-changing dynamics of surgery.

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. You decide to speak with the pharmacist while he is filling the order. What would be the most appropriate thing to say? a) "Did you check the bottle from which you're dispensing that medication?" b) "I am concerned there is a safety issue here." c) "What are you doing? Can I help?" d) "Stop filling that prescription right now or I will be forced to call the manager."

b) "I am concerned there is a safety issue here." When speaking up, it is important to use clear, direct language. Words like "safety" or "concerned" can get people's attention. Hinting at a problem, such as in Answer A, is not sufficient. Likewise, using threats, as in Answer D, is not professional behavior. Answer C is the vaguest option, and it's least likely to result in a solution to the problem.

Add more nurses to a unit. a) Strong b) Intermediate c) Weak

b) Intermediate A decreased workload may decrease errors because staff members are not rushing around as much. However, adding more people doesn't automatically lead to safer care.

Replace all IV pumps in the hospital with a single model. a) Strong b) Intermediate c) Weak

a) Strong Standardization of equipment is a powerful way to reduce the likelihood of errors.

Remove unnecessary and dangerous steps from a process. a) Strong b) Intermediate c) Weak

a) Strong This simplifies the process and thus makes it less prone to error.

intermediate action

An intermediate action is likely to control the root cause or vulnerability. It employs human factors principles, but it also relies upon individual action such as a checklist or cognitive aid.

Redundancies are needed in which of the following circumstances? Select all that apply a) When a secondary system is needed in the event a first system fails b) Within any process in health care c) Within a situation where a failure in the first step can result in serious harm d) Within processes in which redundancies will not take more time

Answer: A and C. Although not every process in health care requires a redundancy, it is important to have one when a primary system can fail and such failure would result in harm.

Add a checklist for a surgical procedure. a) Strong b) Intermediate c) Weak

B) Intermediate Checklists are only effective if they are used - and if the items on the checklist really have a strong connection to patient safety.

Strong action

A strong action is likely to eliminate or greatly reduce the likelihood of an event. It uses physical plant or systemic fixes with application of human factors principles.

weak action

A weak action by itself is less likely to be effective. It relies on policies, procedures, and individual action.

Karen is a pediatric nurse with more than seven years of experience. She cares for many sick children: Some cases are simple, others complex. Working in this environment, Karen and her colleagues experience emotions ranging from joy to pain. It has been a particularly hectic week for Karen. Not only are three staff nurses out on leave, but the float and per diem nurses brought in to help have little pediatric experience. Earlier in the week, Karen switched shifts with another nurse and worked an evening shift and then the following morning shift. On the final shift for this long week, Karen is on the evening shift again. Karen checks the electrodes taped to the chest of a four-year-old girl. After pulling up the bed sheet and helping the little girl get comfortable, she intends to reconnect the lead into the cord from the heart monitor machine located at the bedside. With the machine connected, the staff can monitor the patient's condition from the nurses' station down the hall. After pulling up the sheet, Karen hears her name called over the intercom. She has an urgent phone call from her daughter, who is at her friend's house and is not feeling well. Karen's daughter needs someone to pick her up and bring her home. Which of the following factors affect Karen's ability to reconnect the electrodes? Select all that apply. a) Fatigue b) Stress c) Inadequate training d) Interruptions

A, B, and D are correct. Karen is tired after her multiple shifts, stressed out and distracted by her daughter's sudden illness, and interrupted by the phone call from her daughter.

Would a checklist have been useful to lessen the opportunity for error? a) Yes b) No

Answer: A. A checklist at the nurse handoff would have reminded the nurses to discuss the condition of the pump.

Karen is a pediatric nurse with more than seven years of experience. She cares for many sick children: some cases are simple, others complex. Working in this environment, Karen and her colleagues experience emotions ranging from joy to pain. It has been a particularly hectic week for Karen. Not only are there three staff nurses out on leave, but the float and per diem nurses brought in to help have little pediatric experience. Earlier in the week, Karen switched shifts with another nurse, and she worked an evening shift and then the following morning shift. On the final shift for this long week, Karen is on the evening shift again. Karen checks the electrodes taped to the chest of a four-year-old girl. After pulling up the bed sheet and helping the little girl get comfortable, she meant to reconnect the lead into the cord from the heart monitor machine located at the bedside. With the machine connected, the staff can monitor the patient's condition from the nurses' station down the hall. After pulling up the sheet, Karen hears her name called over the intercom. She has an urgent phone call from her daughter. She is at her friend's house and is not feeling well. She needs someone to pick her up and bring her home. After completing the phone call, Karen remembers she needs to reconnect the heart monitor machine. She returns to the bedside and looks down to find a cable hanging near the side of the heart monitor. She grasps the cable with her right hand. In her left hand, she holds the lead connected to the electrodes on the patient's body. This cable terminates in a circular six- point connector used on EKG leads. To connect the cable to the monitor, the cable has to be held in the proper orientation. Just as Karen is about to trace the origin of the line in her right hand, Joan, the per diem nurse, sticks her head in the doorway to ask for the telephone number to call to have the bed in the next patient room repaired. Karen looks up. Always willing to help, she explains who to call and what forms need to be filled out. "By the way, the forms are on the intranet. The secretary is gone. I will have to help you print one out." After helping Joan, Karen returns to the task of connecting the EKG monitor. She again grasps the six-point connector. Little does Karen know that the power cord for the recently purchased portable IV pump, which is delivering medication to the little girl and located near the bedside, has a similar six-point connection. The nurse who cared for the child during the day shift had disconnected this IV power cable from the pump and placed it near the EKG machine. When she handed the patient off to Karen, she forgot to inform her that the pump was running on battery power. Karen finally attempts to connect the lead in her left hand to the cable in her right hand. At first, she cannot insert the lead connector. She turns the connector to align the prongs and, with some force, pushes the cables together. In an instant, the lethal current of electricity streams through the cord of the IV pump through the EKG lead. The circuit is completed as the current makes its way through the girl's body. Karen immediately realizes her mistake. If you were redesigning the environment, processes, and systems within which Karen functioned, what design strategy would you use to prevent her from connecting the electrical cord to the EKG monitor? a) Forcing function b) Constraint c) Double check

Answer: A. The connection should be designed so that it is not possible to connect the two different cords. A constraint would have made it difficult to connect but not impossible. A double check could still fail if the individual double-checking made the same mistake. When the risk of failure or harm is high, forcing functions should be used.

After the phone call, Karen remembers she needs to reconnect the heart monitor machine. She returns to the bedside and looks down to find a cable hanging near the side of the heart monitor. She grasps the cable with her right hand. In her left hand, she holds the lead connected to the electrodes on the patient's body. This cable terminates in a circular six-point connector used on EKG leads. In order to connect the cable to the monitor, the cable has to be held in the proper orientation. Just as Karen is about to trace the origin of the line in her right hand, Joan, the per diem nurse, sticks her head in the doorway to ask for the telephone number to call to have the bed in the next patient room repaired. Karen looks up. Always willing to help, she explains who to call and what forms need to be filled out. "By the way, the forms are on the intranet. The secretary is gone. I will have to help you print one out." After helping Joan, Karen returns to the task of connecting the EKG monitor. She again grasps the six-point connector. Karen does not know that the power cord for the recently purchased portable IV pump, which is delivering medication to the little girl and located near the bedside, has a similar six-point connection. The nurse who cared for the child during the day shift had disconnected this IV power cable from the pump and placed it near the EKG machine. When she handed the patient off to Karen, she forgot to inform her that the pump was running on battery power. Karen finally attempts to connect the lead in her left hand to the cable in her right hand. At first, she cannot insert the lead connector. She turns the connector to align the prongs and, with some force, pushes the cables together. In an instant, the lethal current of electricity streams through the cord of the IV pump through the EKG lead. The circuit is completed as the current makes its way through the girl's body, killing her instantly. Karen immediately realizes her mistake, and is devastated. Karen ultimately makes the mistake because of the following issues: a) She is not a competent nurse. Select all that apply. b) She is not paying close enough attention to what she is doing. c) She is distracted and fatigued. d) Equipment design has increased her risk for making a mistake.

The correct answer is C and D. As we have discussed in this lesson, just trying harder and paying closer attention won't mitigate the effects of contributory factors both internal and external — such as fatigue and distraction. Any nurse could have made this same mistake, given the circumstances. To prevent this type of mistake in the future, the organization must design an environment that mitigates the effects of these factors and reduces the likelihood of making a mistake.

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. After you speak up, which of the following responses by the pharmacist would best indicate that this pharmacy has a culture of safety? a) "Thanks! I'll tell your supervisor that you helped me today." b) "If you know what's good for you, you won't tell anyone about this." c) "Thanks! But in the future, please correct me in private, when others aren't around." d) "Thanks! I appreciate that. But don't ever say something like that to the other pharmacist here. He's got quite a temper."

a) "Thanks! I'll tell your supervisor that you helped me today." In a culture of safety, all individuals value safety. Those who help prevent errors should be rewarded, not punished or told not to repeat their behavior. If this were an especially strong culture of safety, the pharmacist would also suggest sharing his error with the rest of the staff and changing the system to make medication mix-ups less likely. Answer B is threatening and Answer C is likely to be confusing to the learner. Answer D shows that although this pharmacist may value safety, the rest of the group does not.

The RCA team prepares and shares a summary of their work. What should it contain? a) A clear description of what happened, root causes, and recommendations for prevention. Team members and methods should be included. b) A clear description of what happened, root causes, and recommendations for prevention. Estimated costs for implementation should be included. c) A general description of what happened, root causes, and recommendations for prevention. Team members and methods should be included. d) A general description of what happened, root causes, and recommendations for prevention. Estimated costs for implementation should be included.

a) A clear description of what happened, root causes, and recommendations for prevention. Team members and methods should be included. Communicating the findings of an RCA is a crucial step towards improving patient safety. A presentation (or report) should include a clear description of what happened, the root causes of the event, and recommendations for how to prevent the error from occurring again - mirroring the goals of the RCA itself. It should also describe who was on the RCA team and what methods they used to gather and interpret information.

The first time you admit a patient to the hospital using the new EHR, you see a screen pop up as you are attempting to enter orders. At the top it says, "You must enter orders for DVT (blood clot) prevention before completion of this admission order set. Click here to complete this order." This pop-up box is an example of the use of: a) A forcing function b) Simplification c) Redundancy d) A and B

a) A forcing function Forcing functions make it impossible to skip a task. Just as you cannot put a car into reverse unless your foot is on the brake, you cannot complete this particular admission order in this EHR unless you address the prevention of blood clots. This is not an example of simplification, as it actually adds a step. At the same time, it's not repeating a step, so it's not an example of redundancy.

What is "SBAR"? a) A system for delivering information b) A system for identifying areas for improvement c) A system for confirming receipt of information d) A system for assessing patient values

a) A system for delivering information SBAR, which stands for "Situation-Background-Assessment-Recommendation," is a system for delivering information. It is an adaptation of a US Navy communication technique and can be an effective means to communicate urgent patient care issues.

It's a Tuesday morning, and you and your colleagues are waiting in the OR for the arrival of the surgeon. She is running 30 minutes late. As you prepare for the surgery, you chat with your colleagues about their weekends. The surgeon arrives and says, "Hi, I'm Mary Birru. I apologize for being late; one of my other cases ran long. Before we get started, let's go around the room and introduce ourselves. I want to make sure we're all on the same page." Everyone on the team does brief introductions. The surgeon encourages everyone to participate in the process and says, "If you see something troubling or have a question, please speak up." The team conducts a time-out to confirm the correct patient and surgical site and discusses a few of the issues that may come up during the case. At the end of surgery, the surgeon thanks every team member by name and asks for input on what went well and what could be improved. This example describes a team that: a) Demonstrates effective communication and teamwork b) Has limited communication and does not work as a cohesive group

a) Demonstrates effective communication and teamwork This team works as a cohesive group. Every member's input is valued, and they frequently communicate to ensure the safest possible care. The team does not assume safe care, but takes the time to communicate and assure it.

Your hospital is implementing an electronic health record (EHR) and is teaching all staff how to use it. As you go through the EHR training, you notice that it takes five clicks to bring up the vital signs for a patient. In the past, when you wanted to see a patient's vital signs, you could simply look at the sheet of paper clipped onto the end of the bed. Which of the following likely needs to be improved about the new process to review vital signs? a) It needs to be simplified. b) It needs to be standardized. c) It needs redundancies added. d) It needs to avoid reliance on memory.

a) It needs to be simplified. A process that has a lot of steps — some of which seem unnecessary — is a prime target for simplification. This is especially true for commonly used processes, such as reviewing and recording vital signs.

When considering your role within a health care team, it is important to keep in mind that: a) No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective. b) You may be part of a team, but will likely be able to work autonomously without much input or help from others. c) Teamwork skills will come naturally to you, because we all learn them in other settings. d) You will need to be a good team member until you become an expert in your field, at which point you probably won't need teamwork skills

a) No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective. If you're entering any field in which you'll be caring for patients, it's a certainty that you will be a member of a team; in fact, you may be a member of multiple teams. As such, you'll have the responsibility to communicate effectively, value the contributions of other members, and keep building your team's ability to provide excellent care. Teamwork skills don't come naturally to everyone (Answer C), but anyone can learn and practice them.

Prathibha, a 29-year-old woman, is recovering from same-day knee surgery. While in the post-anesthesia care unit (PACU), she unexpectedly goes into acute respiratory failure and requires intubation. Because she is a young, healthy woman with no medical problems and this was a very unexpected outcome, the charge nurse convenes a team to conduct a root cause analysis. As the RCA for this case begins, the team struggles with identification of the root causes of the outcome. They consider the patient's characteristics as well as the work environment. According to Charles Vincent, what other areas should they consider? a) Team factors, institutional context, and organizational factors b) Budget, human nature, and organizational factors c) Team factors, human nature, and PDSA cycles d) Psychology, PDSA cycles, and management factors

a) Team factors, institutional context, and organizational factors In his papers on this topic, Charles Vincent lists seven categories of factors that influence medical practice and error. These include patient characteristics, task factors, individual staff member characteristics, team factors, work environment, organizational and management factors, and institutional context.

LaTonya, a young woman with diabetes, dies after being admitted for a kidney infection. What might an RCA NOT be able to uncover? a) The medical resident caring for her did not know the appropriate antibiotics for this type of infection. b) There are 23 steps between ordering an antibiotic and administering it on the unit. c) The new electronic medical system does not have a mechanism to flag "stat" antibiotics for pharmacy. d) Fatigue among residents is contributing to unsafe care.

a) The medical resident caring for her did not know the appropriate antibiotics for this type of infection. One concern with RCAs is that by focusing upon systems, those reviewing errors may overlook issues that point to individual issues, such as deficits in knowledge. Answers B, C, and D describe clear system issues that would likely be uncovered through the RCA process.

Why should a RCA be conducted by a team rather than by an individual? a) Understanding what led to an error requires diverse perspectives. b) A team helps the RCA move more quickly. c) Individuals usually are not equipped to complete the intense RCA process on their own. d) Teams are better able to stand up to the conflict that usually comes about when the results of the RCA are made public.

a) Understanding what led to an error requires diverse perspectives. Health care is complex. Discovering why an error took place requires multiple perspectives from people in different professions. Working in a team may upon occasion slow the process down, but it will improve the quality of the outcome.

Which is an important approach when conducting an RCA? a) Use categories to organize events that led to errors. b) Focus on a single process in order to consider it in depth. c) Consider the costs involved in addressing the problems found during the process. d) Avoid focusing on patterns.

a) Use categories to organize events that led to errors. In an RCA, we group the events that led to the error (or near miss) into categories, so that the most important and crucial work processes can be addressed. Discerning patterns of this kind is important, as is considering a broad range of processes from which problems might have arisen. Although costs may need to be considered later on, this is not part of an RCA.

Dr. Jones is having a very busy day in the internal medicine clinic. The printer that he uses to print computerized prescriptions for his patients is out of ink. He is already running 45 minutes behind but is trying to take good care of Mr. Diaz, who has hypertension and diabetes. Dr. Jones quickly hand-writes a prescription for an antihypertensive and gives it to Mr. Diaz. The pharmacy misreads the prescription and dispenses a dose 10 times greater than Dr. Jones intended. Later that evening, Mr. Diaz gets dizzy and falls down the stairs. Would an RCA be useful in this case? a) Yes b) No

a) Yes Yes. This case is a series of small steps that led to an unfortunate and unintended event. Dr. Jones wanted to provide good medical care for Mr. Diaz. The pharmacist wanted to make sure that Mr. Diaz got his medicine. Mr. Diaz wanted to stay healthy, so he took his pills as prescribed, but somehow he ended up injured instead. This would be a good situation for a root cause analysis. Firing Dr. Jones or blaming Mr. Diaz won't prevent this mistake from happening again. An RCA could help prevent falls in the future.

A 62-year-old man with a two-week history of fatigue, shortness of breath, and easy bruising is seen at a primary care clinic on a Saturday morning. Lab work drawn the day before shows the patient to be anemic and having abnormalities with white blood cells. The patient is pleasant, but fatigued, and becomes short of breath walking to the exam room. A blood smear shows numerous abnormal white blood cells. The clinic physician tells the patient that something is wrong with his blood and recommends admission to the hospital. The patient agrees, and the physician calls his colleague in the hospital emergency room. Clinic Physician, " Mr. Chan has a two-week history of fatigue, shortness of breath, and easy bruising. He was seen yesterday with lab revealing a hematocrit" In the question above, does the physician give a complete SBAR through his statements? a) Yes b) No

a) Yes This is a complete SBAR. Within this communication, the two physicians are able to share information quickly and concisely and get the patient the treatment he needs.

It's a Tuesday morning, and you and your colleagues are waiting in the OR for the arrival of the surgeon. She is running 30 minutes late. As you prepare for the surgery, you chat with your colleagues about their weekend. The surgeon enters the room and all talking stops. She smiles briefly and walks toward the patient. She turns to the team and says, "I am late, and we have a patient waiting here, people. Let's get moving and get this done." The team is mostly silent during the procedure. The surgeon has loud music playing and indicates she would rather listen to the music than talk with the team. At the close of the surgery, the surgeon says a brief thank you to the team and leaves the OR. This example describes a team that: a) Demonstrates effective collaboration and teamwork b) Has limited communication and does not work as a cohesive group

b) Has limited communication and does not work as a cohesive group This team does not interact well in a professional capacity. Although the surgeon is professional, she does not engage team members, invite participation, and encourage collaboration. The surgeon has clearly told the team that getting the case done so she can get on with her day is the priority, not safe care.

Which of the following is the best recommended action statement? a) The nurse in charge of calling patients with their results should be replaced. b) Have the phlebotomy lab automatically generate a list of patients all patients who had INRs drawn that day and email them to the nurse, with space to note if the nurse has reached the patient with their results, so that 99% of patients receive calls within two days of their results. c) Patients need to have their INRs checked more frequently. d) Patients awaiting lab results should be given access to MyChart, a part of the electronic health record that allows them to access their lab results themselves.

b) Have the phlebotomy lab automatically generate a list of patients all patients who had INRs drawn that day and email them to the nurse, with space to note if the nurse has reached the patient with their results, so that 99% of patients receive calls within two days of their results. Good recommendations contain ideas for improving the system, as well as ideas for measuring that improvement. Answer B has both of these characteristics. A is punitive and not systems-based, and C does not directly address the problem of the lack of follow-up by the clinic. D, although a good idea, does not contain a measurable outcome.

A 62-year-old man with a two-week history of fatigue, shortness of breath, and easy bruising is seen at a primary care clinic on a Saturday morning. Lab work drawn the day before shows the patient to be anemic and having abnormalities with white blood cells. The patient is pleasant, but fatigued, and becomes short of breath walking to the exam room. A blood smear shows numerous abnormal white blood cells. The clinic physician tells the patient that something is wrong with his blood and recommends admission to the hospital. The patient agrees, and the physician calls his colleague in the hospital emergency room. The clinic physician makes the following statements. Which part of the statement is the background? a) I have Mr. Chan, a 62-year-old man whom I believe has acute myelogenous leukemia. b) Mr. Chan has a two-week history of fatigue, shortness of breath, and easy bruising. He was seen yesterday with lab revealing a hematocrit of 24 and numerous immature white cells in the peripheral smear. c) Mr. Chan needs admission and a hematologic workup. d) I'd like to send Mr. Chan to you. He has agreed to admission and can be there in about 30 minutes.

b) Mr. Chan has a two-week history of fatigue, shortness of breath, and easy bruising. He was seen yesterday with lab revealing a hematocrit The correct answer is B, in which the speaker shares history that is relevant to the current situation.

A circulating nurse had performed many tasks flawlessly during a very complicated, seven-hour operation, when a surgeon observed a small piece of lint in the patient's belly button as they were closing the incision. Without stopping to think, he wheeled around, pointed at the nurse, and said, "If this patient gets infected, it will be your fault!" The nurse was devastated. Is the surgeon showing good leadership? a) Yes b) No

b) No By criticizing her publicly and blaming her for the piece of lint, the surgeon eradicated any possibility of teamwork with the nurse. Not only will the relationship between the surgeon and the nurse be different in the future, but this nurse will be far less likely to go out of her way to help the surgeon and much less likely to speak up if she sees him getting into trouble. Any other team members witnessing this episode will also be negatively affected by the surgeon's tone and reaction. They, too, will be hesitant to speak up in the future.

A resident in anesthesia slips partially used bottles of sedatives, narcotics, and anesthetics from the operating room and pain clinic into his pocket when his supervising attending isn't looking. He takes them home for his own use. Later, his roommate finds him passed out and not breathing on the couch in their apartment. Would an RCA be useful in this case? a) Yes b) No

b) No No. An RCA is not appropriate in cases of negligence or willful harm. These cases are better investigated by the police. This case is an example of criminal activity (stealing controlled substances) and gross professional misconduct (illegal drug use). While an RCA might be helpful to improve the way that medications are kept secure, the overall situation is one best left to the authorities. It is important to note that an error is rarely the result of criminal activity.

Mohammed is a respiratory therapist who is going off shift. Sofia is the therapist coming on shift. Two patients are transitioning care from one provider to the other. During the transition, Mohammed and Sofia have a quick conversation in the hall while several people are walking by and patient monitor alarms are going off. They are interrupted two or three times. Neither one of them looks at notes or jots anything down. They just talk: Mohammed: Okay, Mrs. Jones in 406, acute asthma attack, came in last night... Sofia: Got it. Mohammed: Mr. Niemeyer in 411, lung cancer with postobstructive pneumonia, oxygen dependent... Sofia: Right. Do you believe the scenario described above is an effective patient hand-over? a) Yes b) No

b) No The best answer is no. Transitions in care are inherently risky, and ineffective hand-overs can increase the likelihood of error and patient harm. To be effective, a hand-over communication should take place in a quiet area where participants cannot be interrupted. It should involve structured communication techniques. Communication should be two-way and involve active participation from both parties.

An office manager and her staff are opening a new pediatric clinic in a medical office park. She looks around the waiting room and sees uncovered electrical outlets, tables with sharp edges, and a beautiful porcelain vase on a thin wrought-iron pedestal. The office manager begins to worry that the waiting room may not be safe for rambunctious toddlers. Would an RCA be useful in this case? a) Yes b) No

b) No. By definition, RCAs are retrospective: they look back at an error that occurred, often from several perspectives - from the viewpoint of the patient, provider, nurse, supervisor, etc. In this situation, the office manager seeks to prevent error prospectively, before it happens. Other approaches can be used to prevent error prospectively. Failure modes and effects analysis (FMEA), for example, is a type of prospective investigation that's often used to analyze risky procedures and medications. If the office manager is aware of an accident that occurred at another clinic, and seeks to apply lessons learned from an RCA that clinic did, it would be an example of using RCAs to improve care in multiple locations.

Linda, a pharmacist at an outpatient pharmacy for a medium-sized medical group, receives a call from John, a nurse practitioner in the cardiology clinic. John tells Linda he needs to call in a new prescription for hydrochlorothiazide at 50 mg once a day for Ms. Krane. At the end of the conversation Linda says to John, "Okay, so you want Ms. Joanne Krane to have a new prescription for hydrochlorothiazide at 50 mg by mouth once a day. Thirty pills and six refills." What has Linda just done? a) Increased the likelihood of error by repeating an order b) Provided a read back c) Used SBAR in communication d) B and C

b) Provided a read back This is a read back, which is used to confirm receipt of information (SBAR is a system for delivering information). The pharmacist went through the step of verbally verifying the order from the nurse practitioner by repeating it back to him, which can catch mistakes. The additional time that a read back requires is not a waste. In fact, it may make work more efficient by decreasing the need for later calls for clarification.

The team conducting Quinn's RCA begins work. What should their first step be? a) Review the medical literature. b) Review Quinn's medical records and interview providers. c) Develop causal statements using Charles Vincent's framework. d) Review anonymous opinions from providers as to the reasons for this incident, and then construct a list of the most common.

b) Review Quinn's medical records and interview providers. The first step of an RCA is to identify what happened. This can be done by reviewing charts and records, and by interviewing the patient, family, providers, and any other relevant personnel. Reviewing literature and developing causal statements are part of an RCA, but they occur later in the process. Obtaining opinions might be helpful, but this is not a standard part of the RCA.

Which of the following is likely to be the most immediate result of building an effective health care team? a) Less costly health care b) Safer care c) Fewer delays in care d) Elimination of waste in the system

b) Safer care The best answer is that care will be safer. For example, according to The Joint Commission, an estimated 80 percent of serious medical errors can be linked to miscommunication between caregivers when patients are transferred or "handed-over." One of the hallmarks of effective health care teams is frequent, two-way communication — a characteristic that would likely have an immediate and positive effect on care transitions and safety. While better teamwork can lead to fewer delays, elimination of waste, and even less costly care, these results would likely be secondary to an increase in safety.

Which of the following is a basic strategy for minimizing the opportunity for error in a process? a) Reducing reliance on technology b) Standardizing how the process is completed c) Trying harder to perform the process correctly d) A and C

b) Standardizing how the process is completed The science of human factors has helped us identify many design principles that can help prevent errors; standardizing processes is one such principle. Although we shouldn't be overly reliant on technology, technology can often be used to help prevent errors. Simply trying harder is not an effective error-prevention tactic.

At the end of a double shift, an experienced nurse with an excellent track record gives a medication to the wrong patient. Based on human factors principles, what would you guess was the biggest contributor to this error? a) The nurse's training was out-of-date. b) The nurse was prone to error because she was tired. c) The nurse had become complacent and stopped trying hard. d) The nurse deliberately ignored protocol.

b) The nurse was prone to error because she was tired. The nurse was most likely fatigued after a double shift, which made her prone to error. We cannot sustain performance by merely trying hard and paying attention, and fatigue can affect performance no matter how hard you try or how excellent your training may be. When you are fatigued, you need processes that help prevent you from making an error, or mitigate the effects of an error if you do make one.

Which statement best describes a team? a) A group of people who work together b) A group of people who try to accomplish the same goal c) A group of people who work together in a coordinated way, which maximizes each team member's strengths, to achieve a common goal

c) A group of people who work together in a coordinated way, which maximizes each team member's strengths, to achieve a common goal A team is more than just a group of people who work side by side. A team is a group of people who work together in a coordinated way, which maximizes each team member's strengths, to achieve a common goal. Such a group can anticipate mistakes, overcome obstacles, and navigate difficult situations.

What is a culture of safety? a) A place where errors never happen b) A place where errors are always caught c) A place where all staff can talk freely about safety problems without fear d) A place where all staff feel comfortable reporting errors only if they're guaranteed anonymity

c) A place where all staff can talk freely about safety problems without fear Humans, even humans using technology, are fallible. In health care, there will always be errors and near-misses. In a culture of safety, however, people feel comfortable discussing errors and are rewarded for their focus on patient safety. Although an anonymous reporting system may be useful, the fact that it needs to be anonymous may indicate that people don't feel comfortable discussing errors openly.

Which of the following scenarios would call for a root cause analysis? a) An occupational therapist quits after only three days on the job. b) A physician is convinced that there is a better way to deliver pain medications on her unit. c) A social worker catches a patient who is falling out of bed. d) An administrator needs to develop a balanced budget.

c) A social worker catches a patient who is falling out of bed. RCAs can be very useful in health care to address both errors as well as near misses, such as the near-fall in answer choice C.

Quinn is a three-year-old boy with a congenital heart malformation. While recovering in the pediatric intensive care unit after surgical correction, he is accidentally given a tenfold dose of heparin. Although he suffers no permanent injuries, the leadership of the hospital rightly decides to conduct a root cause analysis. As they assemble the team, it is crucial that they do the following: a) Include Quinn's parents. b) Put together a team of mostly nurses and physicians. c) Create a team of members who fulfill several roles. d) Include the health care providers involved in Quinn's care.

c) Create a team of members who fulfill several roles. Root cause analysis teams need to be diverse in order to be able to see as many viewpoints as possible. While patients and families, as well as the providers involved, may be included in the teams, there is by no means consensus about whether to include these individuals. Interprofessional teams are strongly encouraged, but there is no hard-and-fast prescription for which professions should be included or what the balance of the professions should be. Ideally, the team will include people with a strong understanding of the areas and processes involved in the case.

Effective health care teams have several important characteristics, including: a) The ability to rehearse procedures together, like a choir or a sports team. b) Stable membership; that is, they have the same people on the team from day-to-day. c) Effective communication techniques. d) The ability to achieve good results without strong communication.

c) Effective communication techniques. Effective health care teams have a shared goal and effective two-way communication. The membership of the team may change frequently (Answer B), and it's quite possible for a health care team to consist of people who have never worked together before (Answer A). That makes strong, two-way communication a critical part of delivering safe care.

The heart of the RCA process is: a) Doing a complete and thorough reconstruction of what happened before the event. b) Defining what should have happened for the patient. c) Identifying what caused the event. d) Creating a fishbone diagram.

c) Identifying what caused the event. The heart and soul of an RCA is the identification of the root causes of an error, so that the organization can change the system to prevent similar future errors. Although the other answers are all steps in the RCA, they are not the central feature of the process.

When attempting to decrease the risk of error, it's important to use human factors principles because: a) If you understand the factors that cause people to make mistakes, you can hire safer providers. b) If you understand human factors principles, you can ensure your system is perfectly safe. c) If you understand the factors that affect human performance on critical tasks, you can design a safer system. d) If you understand human factors principles, you can always justify using the latest technology at the bedside.

c) If you understand the factors that affect human performance on critical tasks, you can design a safer system. Understanding how factors that affect human performance (such as fatigue, stress, and poor lighting) affect work and detract from one's ability to execute a safety-critical task (such as administering a medication, filling a prescription, or writing an order) can help you design processes and systems in ways that make them safer.

What else should the leadership do as they plan for the RCA? a) Wait to conduct the RCA for a period of time, in order to let the emotions surrounding the incident subside. b) Make sure that the team conducting the RCA is clear about what they can and cannot review from the records. c) Make sure the team has time and resources to conduct the RCA, including access to advisors when necessary. d) Make sure there is at least one member of the senior leadership on the team.

c) Make sure the team has time and resources to conduct the RCA, including access to advisors when necessary. Conducting a high-quality RCA takes time and resources, and it is important that leadership makes sure these are both available to the team members. Senior leadership does not need to be on the team itself, and senior leaders may even be an impediment to drawing candid answers out of front-line staff. RCAs should be conducted quickly, before memories fade and attention is turned to newer problems.

With whom should the team share the report? a) All providers in the hospital and the public relations office b) The public relations office c) Practice leadership and the hospital leadership d) Hospital leadership and the public relations office

c) Practice leadership and the hospital leadership When communicating about the RCA, a final report or presentation to administrators and stakeholders is the minimum. Some of the individuals who should receive the report include organization leadership, department heads of those departments involved in the event, and members of the risk management and quality improvement departments. Teams may also share the report with the individuals involved in the incident, as well as the patient and his or her family. This underscores the fact that the RCA process is about improving patient care and not placing blame. If written in a blame-free tone, the RCA report helps those who were involved in an error move from possible guilt to action and prevention.

Effective team leaders: a) Have multiple degrees. b) Are usually physicians. c) Seek input from all members of the team. d) Know the correct answer in any given situation.

c) Seek input from all members of the team. Effective team leaders are not necessarily the ones with the most training, the most degrees, or the highest salary. And they don't always have all the answers. They do, however, seek feedback from all team members, recognizing that one person can't provide safe care alone.

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. Why should you tell the pharmacist about your concern? a) So that the pharmacist will think well of you when completing your evaluation at the end of the rotation b) So that you can make your knowledge and eye for details apparent c) So that the patient does not experience an adverse event d) So that the pharmacist gets some extra training

c) So that the patient does not experience an adverse event Speaking up about safety concerns should be a patient-centered act. Your goal in voicing your concern is simply to ensure the patient receives safe and effective care — in this case, the correct medication. Voicing your concern should not be about displaying your knowledge, currying favor, or getting someone in trouble.

Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left ankle was operated upon rather than his right ankle. The surgical staff that operated on Mr. Reynolds is embarking on a root cause analysis (RCA) of the incident. If they complete a high-quality RCA, which of the following is an example of the kind of root cause they might identify? a) The nurse did not listen to the patient. b) The patient was male. c) The hierarchy in the operating room had a negative effect upon communication. d) In this particular case, there was nothing that anyone on the surgical team could have done to prevent an error such as this one.

c) The hierarchy in the operating room had a negative effect upon communication. RCAs are meant to identify system failures that might place patients at risk for similar errors in the future. Poor communication due to hierarchy is one such reason. The nurse's failure to listen to the patient would be a symptom of the larger, "big-bucket" problem.

As a nurse practitioner in a small, rural urgent care clinic, you believe that your clinic team works well together. Which of the following facts would best support your belief? a) Not a single complaint about unprofessional behavior has been filed by clinic members over the past year. b) The providers work in rotating shifts and rarely need to transmit information from one shift to the next. c) The team routinely takes a moment to discuss the plan and voice concerns before doing a procedure. d) All of the above.

c) The team routinely takes a moment to discuss the plan and voice concerns before doing a procedure. One of the main characteristics of strong health care teams is effective and frequent communication. The absence of unprofessional behavior (Answer A) does not necessarily mean the team is effective. And the failure to share information during shift changes is risky for patients (Answer B).

The RCA team working on Peter's case develops several recommended actions. Which of the following is likely to have the strongest impact? a) Assign more staff to the job of calling patients with their INR results. b) Post signs reminding the staff to call patients with their INR results. c) Work with the phlebotomy lab to automatically generate the names of all patients who had INRs drawn that day and send them in an email to the nurse responsible for patient follow-up. d) Create a policy that specifies that patients with INRs must be called with their results within one week.

c) Work with the phlebotomy lab to automatically generate the names of all patients who had INRs drawn that day and send them in an email to the nurse responsible for patient follow-up. Actions that are likely to have a strong impact rely on systemic fixes, such as creating a new process where none existed before. A process in which multiple departments work together to identify patients needing a phone call would likely have a strong impact. Posting signs may be a useful cognitive aid with intermediate impact; however, creating a policy or simply giving a job to more people without a clear process is likely to have a weak impact.

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. Which of the following is a factor that might make it difficult for you to say something to this pharmacist? a) You're just a student, and health care is hierarchical by design. b) The pharmacist got annoyed when someone corrected him earlier. c) You do not have time to say anything today. d) A and B

d) A and B The best answer is A and B. While challenging authority figures requires courage in any field, the hierarchical nature of health care can make speaking up particularly difficult. This is especially true when senior practitioners get upset with junior staff who voice concerns about safety. Other reasons it may be hard to say something in this case include your respect for the pharmacist, concern that you are mistaken, and fear of being yelled at or mistreated. For learners, there's the additional worry that your evaluations and grades may be affected. However, it is always your place to speak up where safety is concerned, even if you're not certain you're right.

Which of the following is an example of unconscious processing by the brain? a) Optical illusions b) Skipping a step on a checklist to save time c) Mistaking one drug for another because of look-alike packages d) A and C

d) A and C Optical illusions and mistakes involving look-alike drugs and names reflect unconscious processing by the human brain. Unconscious processing is a fundamental part of human cognition that can lead to human error even when people are trying their best. Safe systems take these known characteristics of human cognition into account to help people do things the right way.

When teams communicate poorly in health care, consequences can sometimes include: a) Providing care with incomplete or missing information b) Confusion during transitions in care c) Team members not speaking up about their concerns d) All of the above

d) All of the above A critical element in effective teamwork is communication. Teams that do not communicate well are not truly teams, but merely groups of individuals working side by side. According to The Joint Commission, communication failures between care providers or between care providers and patients and families is consistently the main underlying cause of serious adverse events.1 All of the above choices are some of the potential consequences of poor communication. When health care teams do not communicate effectively, bad things can happen.

Human factors is the study of: a) Interactions among humans b) Interactions between humans and machines c) Interactions between humans and the environment d) All of the above

d) All of the above Human factors is an established science that uses many disciplines to understand how people perform under different circumstances. This engineering discipline deals with the interface of people, equipment, and the environment.

Your hospital is implementing an electronic health record (EHR) and is teaching all staff how to use it. As you go through the EHR training, you notice that it takes five clicks to bring up the vital signs for a patient. In the past, when you wanted to see a patient's vital signs, you could simply look at the sheet of paper clipped onto the end of the bed. At the end of your training session on the new EHR, you are handed a two-sided laminated card titled "Quick Start Guide." It provides step-by-step instructions for basic tasks such as entering orders and writing daily notes in the EHR. This is an example of: a) Using forcing functions and constraints b) Automating carefully c) Simplifying d) Avoiding reliance on memory

d) Avoiding reliance on memory Checklists, such as the laminated guide, alleviate your reliance on memory to help make sure you perform a given process (which is not automated and relies on you) correctly. There is nothing forcing you to use this checklist, and it isn't simplifying the steps in the process — just helping you remember them.

You are a member of an intensive care unit team in a regional hospital. This morning, a patient had an unexpected severe allergic reaction (anaphylaxis) after being given a penicillin derivative. There was a significant delay in getting the physician involved and beginning treatment for this life-threatening condition. Fortunately, the patient is now stable and does not seem to be experiencing any lasting effects. At this point, what would an effective team leader do? a) Report this adverse event in the anonymous reporting system so that it can be investigated b) Ask administrators to launch an investigation immediately to find out who was responsible for this adverse event c) Add this medication to the patient's allergy list d) Conduct a debriefing

d) Conduct a debriefing Debriefings occur after events to find out what happened and what could be done better next time. The most effective debriefings happen soon after the event, while memories are fresh. However, the first priority is the patient's health - so debriefings should only occur after the patient is stabilized.

You are a member of an intensive care unit team in a regional hospital. This morning, a patient had an unexpected severe allergic reaction (anaphylaxis) after being given a penicillin derivative. There was a significant delay in getting the physician involved and beginning treatment for this life-threatening condition. Fortunately, the patient is now stable and does not seem to be experiencing any lasting effects. The unit leaders are trying to figure out what changes they should make to prevent this treatment delay from happening again. Given what you know about the incident, what change would you recommend? a) Implement mandatory debriefings after the team works together on a patient. b) Fire the physician who failed to respond in a timely way. c) Stop using nursing assistants in the ICU. d) Implement the use of critical language in the ICU.

d) Implement the use of critical language in the ICU. Critical language (such as "I need some clarity") is an agreed-upon phrase or set of words that indicates to all members of a patient care team that there is a problem. It helps individuals who need to call attention to a problem but don't know what to say, especially if the patient is awake and listening; and it also serves as a red flag to team members that they need to stop and pay attention. Critical language might have helped the nursing assistant speak up more quickly when he observed problems with the patient's breathing. Debriefings, which occur after the event, would be a valuable source of learning, but they would not be sufficient to prevent an event like this one in the future.

Which of the following statements about redundancies within processes is always true? a) They are needlessly inefficient. b) They remove the opportunity for error. c) They require two people to do the work of one. d) None of the above

d) None of the above None of these statements is always true. In high-risk situations — such as the medication administration process — you may need redundancy to ensure safety. Although a typical redundancy involves one person checking the work of another, you can also use technology to "double check." It's important to keep in mind that it is possible for two people to make the same mistake and double checks can still allow the opportunity for error.

Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left ankle was operated upon rather than his right ankle. The team conducting the RCA of the wrong-site surgery realizes that one contributing factor was the pressure on surgical teams to start and end surgeries on time (so as not to disrupt later scheduled procedures). Which of Vincent's seven categories of factors influencing clinical practice does this best illustrate? a) Patient characteristics b) Team factors c) Individual team member d) Organizational and management factors

d) Organizational and management factors When conducting an RCA, it is important to take a balanced look at errors. Charles Vincent identified seven categories of factors that influence clinical practice, including the four above. All seven should be considered when conducting an RCA. The pressure to complete surgeries on time most likely has its origin in organizational and management decisions.

What are some of the limitations of RCAs? a) They are often conducted by those unfamiliar with the local context of the error and do not always produce actionable recommendations. b) People participating in the RCA may not be familiar with how to conduct them, and the costs of implementing the actions may be too high. c) They are often conducted by those unfamiliar with the local context of the error, and the costs of implementing the actions may be too high. d) People participating in the RCA may not be familiar with how to conduct them, and they do not always produce actionable recommendations.

d) People participating in the RCA may not be familiar with how to conduct them, and they do not always produce actionable recommendations. Individuals conducting RCAs in organizations are not always trained to do so, making the exercise difficult to complete. In addition, it can be quite difficult in some cases to find systematic changes that will prevent future errors.

Prathibha, a 29-year-old woman, is recovering from same-day knee surgery. While in the post-anesthesia care unit (PACU), she unexpectedly goes into acute respiratory failure and requires intubation. Because she is a young, healthy woman with no medical problems and this was a very unexpected outcome, the charge nurse convenes a team to conduct a root cause analysis. Which of the following is an example of the type of causal statement that this team might expect to develop? a) Prathibha hid her diagnosis of asthma, so the team was not aware of her respiratory risks. b) The nurse responsible for Prathibha was unqualified to monitor complex medical patients. c) Respiratory compromise can occur in patients with underlying conditions post-operatively. It is unlikely that this outcome could have been prevented. d) The patient was unattended for 30 minutes because the nurse was busy caring for other patients, and this contributed to the outcome.

d) The patient was unattended for 30 minutes because the nurse was busy caring for other patients, and this contributed to the outcome. RCAs are about identifying systems-based issues that contributed to an error, so that these issues can be corrected. Blame, such as in A and B, is not part of RCAs. Answer C is also incorrect, as there are almost always other factors that contributed to the error.

In Margaret's case, Peter, Amy, Jorge, and Teddy came to work planning to do a good job. They didn't intend for Margaret to die, and neither did anyone else in the hospital. Each of these individuals was known as a smart, well-trained person. But somehow, things went horribly wrong. Let's think about Margaret's case yet again, using what we've just learned about a systems approach to error. In the list of factors below, which do you think are the true underlying causes of Margaret's death? Select all that apply. a) Amy is a new employee on the unit. b) Margaret has dementia. c) Jorge switched Margaret to an oxygen mask. d) It was a busy day for Jorge. e) Jorge conveyed the change to Peter verbally and in passing. f) The hospital doesn't have an effective protocol to care for patients with dementia. g) Peter and Amy did not communicate about Margaret's oxygen. h) Teddy was late picking Margaret up for her test. i) Peter came to work intoxicated.

f) The hospital doesn't have an effective protocol to care for patients with dementia. The best answer is probably F -- the hospital doesn't have an effective protocol to care for patients with dementia.

In 2008, two pilots on a regional flight fell asleep at the same time and flew the plane 30 miles past its destination in Hawaii into open ocean. Air traffic controllers tried to contact them nearly a dozen times during 17 minutes. An investigation found that one pilot's sleep apnea, which caused him to lose sleep at night and feel fatigue during the day, as well as long work hours, contributed to the incident.3 In this scenario, an illness and fatigue (and possibly boredom) were internal factors that contributed to the error. Can you identify the external factor that contributed to the error in this scenario?

long work hours were a factor related the individuals' environment that contributed to the error.