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PS101: Introduction to Patient Safety, IHIPS 102, IHI PS 103, IHI PS 104, IHI PS 105
How many new drugs does the FDA's Center for Drug Evaluation and
Research approve every year?
A. Less than 10
B. 10 to 20
C. More than 20 - correct answer ✔C
In 2017, the FDA's Center for Drug Evaluation and Research approved 46
novel drugs. The ten-year graph below shows that from 2008 through 2016, it
averaged about 31 new drug approvals per year.
Janet is especially busy because one of her colleagues called out sick, and
she needs to collect blood samples for four patients. She collects one sample,
and before she gets a chance to label it, another patient in an emergency
situation needs her help. She leaves the unlabeled specimen on the nurses'
station for a moment. When Janet returns, there is a second unlabeled vial of
blood at the nurses' station. She realizes another nurse was obtaining blood
samples and was also called away. Neither nurse knows which vial belongs to
which patient.
What about this scenario seems to make an adverse event likely to occur?
(Choose all that apply.)
A. Janet is not trying hard enough at her job.
B. Janet is juggling multiple tasks at once.
C. Janet was interrupted in the middle of a task with inherent room for error.
D. There are not enough staff members to keep up with the demands of care.
- correct answer ✔B, C, D
,A patient is scheduled for surgery on her left leg. Initially, an intern prepares
the patient by marking the correct surgical site on the dressing on the leg. The
intern's teammate removes the dressing, but addresses the problem by
marking the surgical site on the patient's skin. However, he uses a water-
soluble marker. The ink becomes smeared and illegible. The attending
surgeon is new and not familiar with the hospital's marking procedures.
Meanwhile, the nurses helping with the surgery are busy preparing the patient
and the operating room. Generally, the operating room schedule is tight, and
everyone is in a hurry to move the surgery forward.
What type of adverse event in particular is more likely to occur because of the
system failures in this scenario?
A. Improper anesthesia dosing
B. Retained foreign body after surgery
C. Wrong site surgery
D. None of the above - correct answer ✔C
Isadora is a first-year surgery resident on her first pediatric rotation. Her
attending (consultant) asks her to immediately start intravenous (IV)
replacement fluids on a two-year-old girl who is experiencing vomiting and
diarrhea. Isadora has recently learned the guidelines for calculating fluid
replacement rates for very small children; however, she confuses them and
picks a rate that is too high.
To prevent this type of error from recurring in this unit, which of the following is
MOST important?
A. An improved culture of safety
B. More severe, well-publicized consequences fro providers who are reckless
C. A change to the system, so it does not rely as heavily on human memory
,D. Clearer medical guidelines for fluid replacement in patients of all ages -
correct answer ✔C
Safety has been called a "dynamic non-event" because when humans are in a
potentially hazardous environment:
A. It takes significant work to ensure nothing bad happens
B. It requires the same kind of thinking that causes problems to set them right
C. It is natural to establish and follow safe practices
D. There is generally a high prevalence of "near-misses." - correct answer
✔A
James is a first-year surgery resident on his first pediatric rotation. His
attending (supervising physician) asks him to start intravenous (IV)
replacement fluids on a two-year-old boy who is having vomiting and diarrhea.
Having trouble remembering the guidelines for calculating fluid replacement
rates for very small children, James asks Maria, a nurse on the unit. Maria
responds, "You're the doctor. It's your job to decide this." James picks a rate
that is much too high, putting the child into fluid overload.
Who is likely to be negatively affected by this medical error?
A. The patient and his family
B. James
C. Maria
D. All of the above - correct answer ✔D
"Patient safety" means:
, A. Eliminating errors and adverse effects to patients associated with health
care
B. Eliminating waste in health care services
C. Eliminating health inequities in all populations
D. All of the above - correct answer ✔A
Approximately what percentage of US adults have experienced a medical
error in their own or a family member's care at some point in their life?
A. 1%
B. 5%
C. 33%
D. 66% - correct answer ✔C
A brain surgeon was about to perform a difficult procedure on a high-risk
patient. Several of the surgical team members had just met for the first
time.The surgeon walked into the room and announced, "Good morning,
team. This is a difficult case, and I'm human like everyone in this room. Please
speak up if you see me about to make a mistake or have a suggestion to
help."She then went around the room and introduced herself to everyone by
her first name.
Is the surgeon showing good leadership?
A. Yes
B. No - correct answer ✔A
For which of the above categories do you think Marx recommended
disciplinary action?
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