From Error to Harm

From
Error to Harm

Multiple Choice

Which of the following best describes the Swiss Cheese Model in the context of preventing errors?

• Multiple defense layers prevent errors when properly aligned.

• Recognizing cognitive biases improves clinical decision making.

• Changing work conditions rather than trying to change humans.

• Focusing on individualperformance only

Poll

In the 'Wrong-Site Block' case, the 'holes in the cheese' were primarily caused by:

• Failures in policies and procedures

• A single, critical technology failure

• The patient's complex medical condition

• One person's lack of attention

Multiple Choice

Dr. Ana relying on memory and performing a vague verbal check instead of a formal time-out is a classic example of

• A latent condition

• A normalizing of deviance

• An active error

• A mitigating barrier

Multiple Choice

The last-minute room change, new nurse orientation, and obscured site marking are all examples of

• The consequences of the error

• The patient's personal risk factors

• Latent conditions that increased the likelihood of error

• The 'mitigating actions' shown in the Swiss Cheese model

Mr. Lim, 75, admitted for dengue, fell from his bed on Day 3, leading to an intracerebral haemorrhage, a persistent vegetative state, and a record-high court award.

Multiple Choice

Mr. Lim falling from his bed and sustaining a head laceration is best described as:

• A near miss

• An adverse event

• A latent error

• A hazard

Multiple Choice

The final outcome, where Mr. Lim remained in a persistent vegetative state and the court awarded RM4.2 million, primarily highlights:

• The success of the neurosurgery

• The severe consequences that can result from a seemingly simple patient safety lapse

• The normal risks associated with a dengue fever admission

• The efficiency of the hospital's emergency response

Multiple Choice

The High Court awarding RM1 million specifically in "aggravated damages" suggests

• The judge was in a particularly bad mood that day

• The initial error was considered minor and excusable

• The court found the circumstances of the failure of care to be exceptionally serious

• This is a standard, automatic fee in all medical negligence cases

Multiple Choice

In both cases, the final adverse event was preceded by hidden flaws (e.g., no mandatory time-out policy, potential for faulty bed equipment). According to the lecture, these "accidents waiting to happen" are best defined as

• Active Errors

• Slips and Lapses

• Latent Errors

• Fumbles

Multiple Choice

A doctor who continues to believe a patient's chest pain is indigestion because the patient is young (the 'anchor'), despite new ECG changes, is demonstrating which cognitive bias?

• Confirmation Bias

• Anchoring Bias

• Affect Heuristic

• Outcome Bias

Multiple Choice

If a risky medical decision happens to result in a good outcome, and the doctor therefore believes it was a good decision, this is an example of what?

• Confirmation Bias

• Anchoring Bias

• Affect Heuristic

• Outcome Bias