IHI PS 102
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?
(A) Long work schedule
(B) Fatigue
(C) Inadequate training
(D) None of the above - answer(A) Long work schedule
To prevent this problem from happening again, which of the following would be the best
course of action?
(A) Punish the resident and the pharmacist for their careless actions.
(B) Require both the resident and the pharmacist to take additional training.
(C) Develop a system that prevents messy handwriting from causing
miscommunication that leads to error.
(D) Ensure that no prescribing physician is ever tired or distracted. - answer(C)
Develop a system that prevents messy handwriting from causing miscommunication
that leads to error.
"Latent errors" are best defined as:
(A) Defects in the design and organization of processes and systems.
(B) Errors in patient care that don't ever result in harm and thus go undetected.
(C) Mistakes in patient care that providers fail to report due to fear of punishment.
(D) Errors in patient care that cause immediate adverse effects. - answer(A) 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?
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?
(A) Long work schedule
(B) Fatigue
(C) Inadequate training
(D) None of the above - answer(A) Long work schedule
To prevent this problem from happening again, which of the following would be the best
course of action?
(A) Punish the resident and the pharmacist for their careless actions.
(B) Require both the resident and the pharmacist to take additional training.
(C) Develop a system that prevents messy handwriting from causing
miscommunication that leads to error.
(D) Ensure that no prescribing physician is ever tired or distracted. - answer(C)
Develop a system that prevents messy handwriting from causing miscommunication
that leads to error.
"Latent errors" are best defined as:
(A) Defects in the design and organization of processes and systems.
(B) Errors in patient care that don't ever result in harm and thus go undetected.
(C) Mistakes in patient care that providers fail to report due to fear of punishment.
(D) Errors in patient care that cause immediate adverse effects. - answer(A) 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?
