IHI PS 105
When an error occurs, which of the following is generally the proper order of
prioritization?
(A) Communicate with the patient, report to all appropriate parties, check the medical
record, care for the patient.
(B) Report to all appropriate parties, check the medical record, care for the patient,
communicate with the patient.
(C) Care for the patient, communicate with the patient, report to all appropriate parties,
check the medical record.
(D) Check the medical record, care for the patient, and communicate with the patient,
report to all appropriate parties. - answer(C) care for the patient, communicate with the
patient, report to all appropriate parties, check the medical record
You're a new resident (house officer). At 2:00 AM, you receive a phone call about a
patient you are covering who has diabetes. The patient has an elevated blood sugar of
375. You order 12 units of NovoLog (rapid-acting) insulin and ask the nurse to check the
sugar again in one hour and call you back. One hour later, the sugar is 280, so you
order another 10 units. By 4:00 AM, the patient's sugar is dangerously low at 45. You
realize that NovoLog insulin takes two to three hours to reach peak effect. By
rechecking the patient's glucose after only one hour and giving more insulin so quickly,
you set the patient up for an episode of hypoglycemia.
Why is it important to communicate with the patient about this event?
(A) Open sharing of this type of information is necessary if patients are to trust their
caregivers.
(B) Open communication with the patient will prevent the same event from happening
again.
(C) Open shari - answer(A) Open sharing of this type of information is necessary if
patients are to trust their caregivers.
Which of the following is true regarding communication about adverse events with
patients?
(A) It is important to have all the facts prior to your initial communication about the
adverse event.
(B) In some cases, the care team may decide for medical reasons to defer
communication with a patient about an upsetting incident.
(C) Due to its complexity, communication with patients following adverse events is best
done by lawyers.
(D) All of the above - answer(B) In some cases, the care team may decide for medical
reasons to defer communication with a patient about an upsetting incident.
If you are responsible for the initial communication with the patient about the error,
which of the following should you be sure to do?
When an error occurs, which of the following is generally the proper order of
prioritization?
(A) Communicate with the patient, report to all appropriate parties, check the medical
record, care for the patient.
(B) Report to all appropriate parties, check the medical record, care for the patient,
communicate with the patient.
(C) Care for the patient, communicate with the patient, report to all appropriate parties,
check the medical record.
(D) Check the medical record, care for the patient, and communicate with the patient,
report to all appropriate parties. - answer(C) care for the patient, communicate with the
patient, report to all appropriate parties, check the medical record
You're a new resident (house officer). At 2:00 AM, you receive a phone call about a
patient you are covering who has diabetes. The patient has an elevated blood sugar of
375. You order 12 units of NovoLog (rapid-acting) insulin and ask the nurse to check the
sugar again in one hour and call you back. One hour later, the sugar is 280, so you
order another 10 units. By 4:00 AM, the patient's sugar is dangerously low at 45. You
realize that NovoLog insulin takes two to three hours to reach peak effect. By
rechecking the patient's glucose after only one hour and giving more insulin so quickly,
you set the patient up for an episode of hypoglycemia.
Why is it important to communicate with the patient about this event?
(A) Open sharing of this type of information is necessary if patients are to trust their
caregivers.
(B) Open communication with the patient will prevent the same event from happening
again.
(C) Open shari - answer(A) Open sharing of this type of information is necessary if
patients are to trust their caregivers.
Which of the following is true regarding communication about adverse events with
patients?
(A) It is important to have all the facts prior to your initial communication about the
adverse event.
(B) In some cases, the care team may decide for medical reasons to defer
communication with a patient about an upsetting incident.
(C) Due to its complexity, communication with patients following adverse events is best
done by lawyers.
(D) All of the above - answer(B) In some cases, the care team may decide for medical
reasons to defer communication with a patient about an upsetting incident.
If you are responsible for the initial communication with the patient about the error,
which of the following should you be sure to do?
