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WorksheetsPatient Safety and Quality Improvement
Total questions: 8
Worksheet time: 9mins
In the hospital, the team accidentally broke confidentiality with a teenage patient regarding her sexual activity and diagnosis of PID to the MOP. Pt and MOP are upset. Problem occurred due to poor hand-off at report. BEST NEXT step?
file a written complaint against the residents involved
initiate a root cause analysis of this sentinel event
recommend text messages for important facts in hand-off
review the hospital’s handoff process, highlighting the importance of both verbal and written communication
In ER with 2 patients: 2 yo with ALL and fever; and 18 yo with dehydration and syncope. Cefipime accidentally ordered and given to 18 yo (dosed for 2 yo, low-dose for 18 yo). 2 yo orders fixed; no reaction to ABX for 18 yo. Now 18 yo is better after IVF, ready to go home. BEST NEXT step?
do not report the error to the hospital or the pt
report the error to the hospital and the pt
report the error to the hospital but not to the patient
report the error to the pt but not the hospital
in clinic, 12 mo has AOM. You order amoxicillin on EMR using weight in chart: unfortunately, weight was entered as 20 kg, not 20 lb. Nurse had made error, Rx sent, but pharmacy called and Rx was eventually fixed. BEST way to prevent similar errors?
counsel the intern on ensuring that the correct weight is used to calculate medication doses
have the clinic supervising attending physician review all prescriptions before the patient leaves the clinic
review medication dose calculations with the parent(s)
standardize the use of kilograms when recording weight for all clinic patients
A parent needs to administer 125 mg of oral amoxicillin liquid (250 mg/5 mL) to their young child. Method MOST likely to reduce the likelihood of a dosing error is to administer the medication using a
medication cup labeled in 2.5-mL increments
medication cup labeled in ½-teaspoon increments
medication cup labeled in ½-teaspoon and 2.5-mL increments
syringe labeled in 0.5-mL increments
After doing a Plan-Do-Study-Act cycle to reduce office visit times for half of clinic pts by checking VS in clinic room, it turns out office visit times increased. It is thought it was due to winter; pts have more coats and boots to remove to get their wt and VS. MOST accurate statement regarding this project is that
implementation on a larger scale would have been more effective in creating change leading to improvement
obtaining VS in the clinic room was an ineffective method of creating change leading to improvement
the best next step is to change the Aim statement of PDSA cycle
the best next step is to do another Plan-Do-Study-Act cycle
A 30 WGA Nb dies in NICU due to hyperkalemia. TPN had potassium at 10 times the normal dose. The medical error is disclosed to the family by the supervising physician. BEST NEXT step for the medical team is
Changing the TPN ordering guidelines
Disciplinary action
Supportive counseling
Education on TPN components
13 yo with CF had pneumonia and treated with amikacin for 4 weeks at home. Supposed to get amikacin levels and check BUN and Cr weekly; Only levels obtained were at your office after treatment over: BUN and Cr are still normal. Pt reports no adverse effects and no hearing loss. BEST description of the medical error in this patient is
commission
non-intercepted
preventable
sentinel
A 4 mo is in PICU for respiratory failure, on ventilator; better, but not quite ready to extubate. Still has some spontaneous movements with lab draws, suctioning; calmed by pain meds, patting, et al. MOST appropriate measure to prevent unplanned extubation in this patient would be to
Administer continuous pharmacologic paralysis
Apply continuous end-tidal carbon dioxide monitoring
Ask the parents to hold the tube in place during episodes of agitation
Ensure a 1:1 nurse-to-patient ratio
