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PS 104_ Teamwork and Communication_Student Version (1
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PS 104_ Teamwork and Communication_Student Version (1
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PS 104: Teamwork andCommunication_Student Version
Referring to Dr. Michael Leonard's video, in your opinion, what was the
underlying cause of the adverse event? - CORRECT ANSWER-The
culture of the hospital did not promote safety as the highest priority.
A healthy 45-year-old athlete is scheduled for a knee arthroscopy to
clean up her knee so that she can ski better in the coming winter. This is
a low-risk, straightforward procedure.
The chief of orthopedics will perform the procedure. After two complex
and time-consuming procedures, this is his final surgery of the day.
Because of a staffing issue, two nurses are pulled from another
operating room (OR) to help. They are experienced nurses but have
never worked in orthopedics before, and they don't know any of their
colleagues.
The surgery begins with limited introductions or discussion about the
case, and the surgeon has loud music playing. He asks one of the two
"new" nurses for 20 mL of local anesthetic with dilute epinephrine to put
in the knee. The nurse hears only, "Give me the epi." Not knowing what
it is for, she hands him a syringe with 20 mL of concentrated
epinephrine, which is 1,000 times too much.
As - CORRECT ANSWER-Acquainted the team members
Verified the experience and comfort level of the team members to
provide the care
Identified what drugs were going to be used
Outlined the plan
Prevented the adverse event
, Two women — one named Camilla Tyler, the other named Camilla
Taylor — arrive at a particularly busy emergency department at about
the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an
antibiotic. The doctor orders the medications, but mixes up the patients
when filling out the order sheets. The pharmacist dispenses the
medications as ordered, and the nurse administers an antibiotic to Ms.
Tyler and a sedative to Ms. Taylor.
What is one of the latent errors in this scenario? - CORRECT
ANSWER-The forms are completed by hand at the same time for
different patients.
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? - CORRECT ANSWER-
"Latent errors" are best defined as: - CORRECT ANSWER-Defects in
the design and organization of processes and systems.
Nearing the end of her 18-hour work shift, a resident sees a patient with
extremely high blood glucose levels. She writes the patient a prescription
for insulin; however, in her exhaustion, she closes her "U" (for "units"),
and it looks more like an extra zero. As a result, the pharmacist
dispenses an insulin dose that's ten times stronger than the patient
needs.
To prevent this problem from happening again, which of the following
would be the best course of action? - CORRECT ANSWER-Develop a
system that prevents messy handwriting from causing
miscommunication that leads to error.
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
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