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PS 102: From error to harm questions
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Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for "units"), and it looks more like an extra zero. As a result, the pharmacist dispenses an insulin dose that's ten times stronger than the patient needs.
Which of the following is a latent unsafe condition in the system that contributes to the resident's
error? ✔✔long work schedule
To prevent this problem from happening again, which of the following would be the best course of action? ✔✔Develop a system that prevents messy handwriting from causing
miscommunication that leads to error.
"Latent errors" are best defined as: ✔✔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? ✔✔The nurse administers an antibiotic to Ms. Tyler and
a sedative to Ms. Taylor.
What is one of the latent errors in this scenario? ✔✔The forms are completed by hand at the
same time for different patients.
According to James Reason, by definition an "unsafe act" always includes: ✔✔A potential
hazard
Anita, a nurse practitioner, is seeing Mr. Drummond in clinic. Mr. Drummond is a 57-year-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? ✔✔lapse
What type of error is this intervention best designed to address? ✔✔lapse
What intervention helped prove that catheter-associated bloodstream infections (CLABSIs) were
preventable consequences of care? ✔✔A checklist of evidence-based practices applied
consistently and collectively every time a catheter is used
What is one reason that patient safety has shifted to work on reducing harm in addition to
preventing errors? ✔✔Harm is more preventable than providers once thought.
Which of the following is included in the IHI Global Trigger Tool definition of harm?
✔✔Physical injury caused by medical care that triggers additional care
The Swiss cheese model of harm illustrates what important concept in patient safety?
(A) Unsafe acts (including errors and violations) are the most important cause of harm to patients.
(B) Both latent unsafe conditions and active failures (unsafe acts) contribute to harm. (C) Harm results when the layers of defense in a system fail to prevent a hazard from reaching a patient.
(D) B and C ✔✔(D) B and C
Why do some patient safety leaders such as Dr. David Bates believe the definition of harm
should be broader than the definition in the IHI Global Trigger Tool? ✔✔Because health care
systems should work to prevent more types of harm than the current definition includes
