Foundations of Patient Safety

Multiple Choice

Which of the following best describes the WHO definition of patient safety?

• Absence of preventable harm and reduction of risk to acceptable minimum.

• Ensuring all patients receive medication on time.

• Providing the latest technology in hospitals.

• Guaranteeing zero errors in healthcare.

Match

Match the following

• A nurse misreads a poorly written medication order but, upon double-checking with the prescriber before administration, realizes the potential mistake and clarifies the correct dose. The patient receives the correct medication.

• I.      A hospital's electronic health record system does not effectively flag critical drug interactions, contributing to a doctor prescribing two incompatible medications

• A patient develops a severe infection following surgery due to inadequately sterilized instruments, requiring prolonged hospitalization and additional antibiotic therapy

• I.      The fundamental obligation to protect patients from preventable injury during their care, based on principles like "do no harm."

• I.      A surgeon unintentionally makes an incision at the wrong vertebral level during a spinal surgery. This action itself is considered as

Near Miss

LatentFailure

Adverse Event

Ethica Imperative

Error

• Near Miss

• LatentFailure

• Adverse Event

• Ethica Imperative

• Error

Multiple Choice

Which of the following are examples of a 'Near Miss' in patient safety?

• EMR alerts doctor about patient's allergy before medication is prescribed

• Patient develops infection after surgery due to sterile technique lapse

• Nurse selects wrong medication due to similar packaging

• Wet floor in hospital corridor without warning sign

Poll

What was the very FIRST breakdown in the safety process shown in the 'Missed Allergy Inquiry' comic?

• The patient's memory faltering

• The rushed interview in triage where history-taking was pushed to the back burner

• The disconnected records system

• The nurse preparing the antibiotic

Multiple Choice

The panel "FORM FILED AWAY" shows incomplete data becoming "complete" in the paperwork. This action represents a critical flaw in which process?

• Medication administration

• Patient transport

• Information management and verification

• Surgical consenting

Multiple Choice

The case shows a known penicillin allergy hidden in another system. This is a perfect example of

• An active failure by the admitting intern

• A departmental silo causing a latent system failure

• A near miss that was successfully caught

• A patient's failure to provide accurate information

Multiple Choice

The final panel proposes a "SYSTEM FIX" requiring "cross-system allergy alerts before any order". This solution aims to create what?

• A stronger administrative control

• A system redesign that acts as a robust layer of defense

• A behavioral control relying on staff memory

• A way to assign blame more easily

Multiple Choice

The "Bedside Verification" panel, where the nurse asks "any issues?" and the patient uncertainly replies, "I... hope this is okay," is a powerful illustration of

• A successful patient engagement strategy

• A moment where both parties feel uncertain, but the system's momentum continues toward error

• A standard procedure that guarantees safety

• The patient giving fully informed consent for the medication

Multiple Choice

The final "SYSTEM FIX" proposed in the 'Missed Allergy' case is a "cross-system allergy alert before any order". This solution is popular among safety experts because it:

• Looks very impressive on the hospital's marketing brochure

• Relies entirely on the doctor's memory, which is the most reliable tool.

• Creates a strong "forcing function" that makes it harder for humans to do the wrong thing.

• Gives the computer something to do so it doesn't get bored

Poll

In the 'Wrong-Site Block' case, which failed defense layer do you think was the most critical point of failure?

• The last-minute room change and new nurse orientation

• The paperwork obscuring the correctly marked site.

• The fact that a formal 'Time-Out' was skipped before the block

• Dr. Ana's vague verbal confirmation

Multiple Choice

The final impact on Mr. J included unnecessary anesthetic risk, emotional distress, and a delayed surgery. These outcomes are collectively defined as

• Medical litigation

• Patient Harm

• Procedural complications

• A blame culture

Multiple Choice

The case highlights several factors: a last-minute room change, a new nurse orientation, and team familiarity being lost. These are all examples of:

• Active errors by the staff

• The patient's personal risk factors

• Environmental and systemic changes that increase the risk of error.

• Expected daily challenges that have no impact on safety

Open Ended

One of the learning objectives for this module is to promote a non-punitive reporting culture. After the 'Wrong-Site Block' was flagged and the anaphylaxis 'Reaction Strikes', the staff involved likely felt immense pressure. Why is it so important for the hospital to 'learn and improve, not blame' in these situations, and what could happen if they chose to punish the individuals involved?"

Multiple Choice

You are a "Systems Architect" reviewing the 'Wrong-Site Block' case. Your job is to find the pre-existing, hidden flaw in the blueprint of the hospital's safety plan. Which of the following is a classic latent failure?

• Dr. Ana administering the block to the wrong wrist.

• The fact that the hospital's pre-procedure 'Time-Out' protocol was not mandatory or was easily skipped

• The patient, Mr. J, experiencing emotional distress after the event

• The operating room being too cold that day