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Patient Safety – Modules Midterm 1 – PS 101, 102, 203, 104 PS 101  The simplest definition of patient safety is the prevention of errors and adverse effects to patients associated with health care  According to WHO, in developed countries worldwide, what is the approximate likelihood that a hospitalized patient will be harmed while receiving care? o 10%  Since the publication of To Err Is Human in 1999, the health care industry overall has seen which of the following improvements? o Wider awareness that preventable errors are a problem  Safety has been called a “dynamic non-event” because when humans are in a potentially hazardous environment: o It takes significant work to ensure nothing bad happens  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 twoyear-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. o To prevent this type of error from recurring in this unit, which of the following is MOST important?  An improved culture of safety and teamwork o Who is likely to be negatively affected by this medical error?  The patient and family, James – the first year surgical resident, Maria – the nurse on the unit  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? o 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. When asked why they failed to follow up, each caregiver said he or she forgot. o Based on what you know, how would you classify the caregivers’ behavior?  Human error o 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?

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 Investigating the problem and seeking systems solutions Why is psychological safety a crucial component of a culture of safety? o It allows people to learn from mistakes and near-misses, reducing the chances of further errors 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? o Accountability Which of these is a behavior providers should adopt to improve patient safety? o Follow written safety proticols, even if they slow you down 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. o Which of the following should you keep in mind as your hospital redesigns the way it handles knee replacements? How system components are integrated with one another is as important as well they function independently o Which of the following is typically true of “weak signals”? 

They can combine with other human or environmental factors to result in catastrophe The term “normalized deviance” refers to: 

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o Acceptance of events that are initially allows because no catastrophic harm appears to result 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: o The nurse administrator did not have the appropriate span of responsibility to engage the system components needed to solve the problem

PS 102

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Which of the following is a latent unsafe condition in the system that contributes to the resident’s error? o Long work schedule To prevent this problem from happening again, which of the following would be the best course of action? o Develop a system that prevents messy handwriting from causing miscommunication that leads to error. “Latent errors” are best defined as: o Defects in the design and organization of processes and systems. 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? o The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor. What is one of the latent errors in this scenario? o The forms are completed by hand at the same time for different patients. According to James Reason, by definition an “unsafe act” always includes: o A potential hazard Anita, a nurse practitioner, is seeing Mr. Drummond in clinic. Mr. Drummond is a 57year-old man with diabetes and chronic kidney disease. Having kept up on the literature, Anita is aware that tightly controlling his diabetes can slow the progression of his renal disease. She discusses her plan to increase his dose of glargine (long-acting insulin) by 12 units per day with one of the family physicians in the clinic, who agrees. At the end of the day, as she is working on her documentation, she realizes she never told Mr. Drummond to increase his insulin dose. This is an example of what type of error? o Lapse

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Roger, a pharmacist in a hospital, is working in the discharge pharmacy filling medications for patients who are going home. He sees a prescription for ciprofloxacin, an antibiotic, and he asks his pharmacy technician Mike to fill it quickly, as the patient is waiting and anxious to leave. Mike checks the shelves and sees they are out of ciprofloxacin, but they do have levofloxacin (an antibiotic in the same class that covers most, but not all, of the same types of infections). Mike knows he should usually check with the prescribing physician before making a substitution. However, in the interest of efficiency in this particular case, Mike deems it OK to go ahead. He substitutes the medications.

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This is an example of what type of unsafe act? o Violation

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Which of the following is the most significant advantage of shifting to a systems view of safety within health care? o 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.  

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What type of error is this intervention best designed to address? o Lapse What intervention helped prove that catheter-associated bloodstream infections (CLABSIs) were preventable consequences of care? o A checklist of evidence-based practices applied consistently and collectively every time a catheter is used What is one reason that patient safety has shifted to work on reducing harm in addition to preventing errors? o Harm is more preventable than providers once thought. Which of the following is included in the IHI Global Trigger Tool definition of harm? o Physical injury caused by medical care that triggers additional care The Swiss cheese model of accident causation illustrates what important concept in patient safety? o Both latent unsafe conditions and active failures (unsafe acts) contribute to harm. o Harm results when the layers of defense in a system fail to prevent a hazard from reaching a patient. Why do some patient safety leaders believe the definition of harm should be broader than the definition in the IHI Global Trigger Tool? o Because health care systems should work to prevent more types of harm than the current definition includes

PS 203 

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A 36-year-old patient with kidney failure comes to the hospital to have a special arteriovenous fistula placed in his left arm to allow him to begin dialysis in a few weeks. The surgical team is about to operate on the wrong arm but a junior member of the care team notices the mistake and speaks up. Which of the following actions is most likely to improve the hospitals safety system? o Engage in open conversation about what happened and why. Which of the following statements is consistent with the definition of a just culture? o systems issues can lead individuals to engage in unsafe behaviors.

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To establish a just culture, Dr. Bob Wachter says we need to balance ______ and ______: o “No blame” and accountability Your clinic is working hard to improve its hand hygiene compliance rates, but the progress has recently plateaued. You survey staff to learn more about their experiences. Which finding would suggest it may be time to start punishing individual providers who violate the hand hygiene policy? o Most staff members find the hand hygiene policy is clear and easy to follow. Which of the following opinions did Dr. Bob Wachter express in his response to Paul Levy’s blog about the wrong-site surgery discussed in this lesson? o Circumstances could exist where the providers were to blame for the error. 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? o 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. o This appears to be an example of which of the following?  Unfair attribution of blame o How do you think the leadership’s decision to fire the employee will affect the safety of the organization?  The system will be less safe because employees are less likely to be honest when they make errors. 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? o Investigating the problem and seeking systems solutions Why is psychological safety a crucial component of a culture of safety? o It allows people to learn from mistakes and near-misses, reducing the chances of further errors. Which of the following is a tool that helps leaders assess culpability after a medical error? o Just culture algorithm As you prepare for your interview, which of the following questions should you plan to ask in order to determine whether the hospital has a culture of safety? o “What is the process to address safety concerns brought forward by the staff?” During lunch on your interview day with some of the nurses from the unit, someone mentions that the opening on the unit came about because they had to fire a nurse

who had violated basic safety procedures multiple times. This nurse, you learn, received supplemental training and several chances to do better, but he continued with the violations until he was fired. Based on this information, what might you infer about the culture of safety in this unit? o The unit has a reasonable culture of safety because it makes a distinction between unsafe processes and unsafe behaviors. 

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On your way off the unit after your interview, you see a physician come up to one of the nurses. The physician asks the nurse if a particular patient has received her antibiotics, two hours after a “stat” order was placed. The nurse replies, “No, pharmacy hasn’t delivered it up yet. I was just about to call them about it.” Which of the following responses by the physician would best indicate that the unit has a culture of safety? o “I know it has been a crazy day. I can call the pharmacy. If you are having trouble getting something done in a timely manner, please tell me.” Which of the following is an effective approach to using data in a culture of safety? o Pair data with human stories to help others understand its importance. Why does Dr. Gerald Hickson refer to safety incidents at his organization simply as “disturbances”? o Because he wants to encourage people to report absolutely anything that could threaten safety.

PS 104 Effective health care teams have several important characteristics, including: 

(C) Effective communication techniques.

Which of the following is likely to be the most immediate result of building an effective health care team? 

(B) Safer care

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? 

(C) The team routinely takes a moment to discuss the plan and voice concerns before doing a procedure.

One reason it’s critical for caregivers to improve their teams’ effectiveness is:  Effective teams reduce the risk of errors by providing a “safety net” for individual caregivers. When considering your role within a health care team, it is important to keep in mind that:  No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective.

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What is “SBAR”?  A system for delivering information 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?  (B) Provided a read back Use the following scenario to answer questions 3-4: 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?  Conduct a debriefing 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?  Implement the use of critical language in the ICU. Effective team leaders:  Seek input from all members of the team.

A patient’s primary care provider (PCP) prescribes him a new diuretic because of a change in his insurance. It is intended to replace his previous medication. However, when he gets home, he is confused and takes both the previous and the new diuretic. He becomes dehydrated and ends up in the hospital. Which of the following process improvements would have been the best option for the PCP to prevent this adverse event?  (B) Using teach-back to confirm patient understanding According to US studies, approximately what portion of serious adverse events can be linked to miscommunication between caregivers when patients are transferred or handed over?  (D) 80 percent Which of the following is NOT always a key part of the medication reconciliation process?  (B) Following up with the patient to ensure he or she takes the medication as prescribed Which is the following statements best describes the role of patients in ensuring safety across the continuum of care?

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(C) Patients often need to be able to act out precise recommendations when they leave the health care setting for home.

A primary care provider (PCP) refers her patient to a specialist for a sleep study. Which of the following steps would represent the END of a closed-loop referral process? (Hint: Think of the nine-step process this lesson recommends).  (D) The PCP discusses the treatment plan with the patient, after communicating about it with the specialist. When speaking with a patient who has limited understanding of health care terminology, which of the following words would you likely want to avoid?  “Adverse”  (B) “Lipids”  (C) “Abdomen”

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