PS 202: POLITICAL THOUGHT AND ANALYSIS –
EXAMINATION
Correct Answer:
By implementing systemic changes in operating rooms
At least half a million deaths per year could be prevented with effective implementation of
systemic improvements in operating rooms. Specifically, multiple studies have found
implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical
morbidity and mortality due to surgical errors. - answers✔✔According to the World Health
Organization (WHO), how could at least half a million deaths due to surgical error be prevented
every year?
(A) By developing better surgical technology
(B) By implementing systemic changes in operating rooms
(D) By inflicting stronger punishments for those who commit medical errors
(E) By weeding out reckless surgeons
Correct Answer:
A and B
The best answer is A and B. According to Levy, multiple factors led to the wrong-site surgery
(which occurred even though the surgical team marked the correct site), one of which was that
the team did not conduct a "time out" safety check, another of which was a broader systems
issue, in that the hospital did not have adequate mechanisms in place to prevent such an error
in an extremely hectic operating room environment. - answers✔✔According to Paul Levy, which
,of the following were factors that led to the wrong-site surgery at Beth Israel Deaconess
Medical Center in June 2008?
(A) The surgical team did not properly follow a "time out" procedure.
(B) There were systemic problems in the hospital.
(C) The surgical team marked the wrong site on the patient.
(D) A and B
Correct Answer:
All of the above
The best answer is all of the above. Paul Levy employed a multi-pronged approach to spread
awareness of the error and the hospital's response to it, as well as collect feedback from the
public. It's critical to communicate effectively after a preventable mistake, as patients often
want to know what steps are being taken to prevent similar mistakes from occurring again.
Further, being transparent about errors allows the entire organization — and even other
organizations — to learn from them. - answers✔✔What did Paul Levy do after handling the
immediate fallout from the wrong-site surgery?
(A) He proposed creating an instructional video about the experience that would be viewed at
meetings and conferences.
(B) He explained the event and the hospital's response to the public in a blog post.
(C) He asked the general public for their thoughts and suggestions.
(D) All of the above
Correct Answer:
Circumstances could exist where the providers were to blame for the error.
, Wachter felt that if the providers were routinely and knowingly negligent — in an environment
where good systems did exist to prevent errors — they could be to blame and punishment
might be warranted. However, it would still be a controversial topic and a tough balancing act of
"no blame" versus accountability. Overall, Wachter praised Levy and commended in particular
his public disclosure of the case. - answers✔✔Which of the following opinions did Dr. Robert
Wachter express in his response to Paul Levy's blog about the wrong-site surgery of June 2008?
(A) Coming out with the error in public was unwise.
(B) The case was clear-cut and should not have been the subject of debate.
(C) It was a mistake not to punish staff for cutting corners and neglecting rules.
(D) Circumstances could exist where the providers were to blame for the error.
Your Answer:
The mistake should be communicated to Ben and the hospital's administrators.
The hospital should communicate right away with Ben and his family about the mistake, and
administrators also need to know about it, so they can start investigating what happened and
changing processes to avoid such an event in the future. It is likely that punishing those involved
should be avoided. Although posting information publically may be a good idea, the patient and
his family must be attended to first. - answers✔✔Ben, a 36-year-old patient with Type I diabetes
mellitus and kidney failure, comes to the hospital to have a special arteriovenous fistula placed
in his arm to allow him to begin dialysis in a few weeks. The fistula was supposed to be placed
on the left arm, but the surgical team accidentally operates on the opposite arm, not realizing
until the procedure is finished. When Ben wakes up from anesthesia, he sees a bandage on his
right arm and is confused. What should happen right away?
(A) The mistake should be communicated to Ben and the hospital's administrators.
(B) The mistake should be posted on a blog along with an explanation of the events.
(C) The entire surgical team should be reprimanded, as it was not only the responsibility of the
surgeon.
(D) All of the above
EXAMINATION
Correct Answer:
By implementing systemic changes in operating rooms
At least half a million deaths per year could be prevented with effective implementation of
systemic improvements in operating rooms. Specifically, multiple studies have found
implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical
morbidity and mortality due to surgical errors. - answers✔✔According to the World Health
Organization (WHO), how could at least half a million deaths due to surgical error be prevented
every year?
(A) By developing better surgical technology
(B) By implementing systemic changes in operating rooms
(D) By inflicting stronger punishments for those who commit medical errors
(E) By weeding out reckless surgeons
Correct Answer:
A and B
The best answer is A and B. According to Levy, multiple factors led to the wrong-site surgery
(which occurred even though the surgical team marked the correct site), one of which was that
the team did not conduct a "time out" safety check, another of which was a broader systems
issue, in that the hospital did not have adequate mechanisms in place to prevent such an error
in an extremely hectic operating room environment. - answers✔✔According to Paul Levy, which
,of the following were factors that led to the wrong-site surgery at Beth Israel Deaconess
Medical Center in June 2008?
(A) The surgical team did not properly follow a "time out" procedure.
(B) There were systemic problems in the hospital.
(C) The surgical team marked the wrong site on the patient.
(D) A and B
Correct Answer:
All of the above
The best answer is all of the above. Paul Levy employed a multi-pronged approach to spread
awareness of the error and the hospital's response to it, as well as collect feedback from the
public. It's critical to communicate effectively after a preventable mistake, as patients often
want to know what steps are being taken to prevent similar mistakes from occurring again.
Further, being transparent about errors allows the entire organization — and even other
organizations — to learn from them. - answers✔✔What did Paul Levy do after handling the
immediate fallout from the wrong-site surgery?
(A) He proposed creating an instructional video about the experience that would be viewed at
meetings and conferences.
(B) He explained the event and the hospital's response to the public in a blog post.
(C) He asked the general public for their thoughts and suggestions.
(D) All of the above
Correct Answer:
Circumstances could exist where the providers were to blame for the error.
, Wachter felt that if the providers were routinely and knowingly negligent — in an environment
where good systems did exist to prevent errors — they could be to blame and punishment
might be warranted. However, it would still be a controversial topic and a tough balancing act of
"no blame" versus accountability. Overall, Wachter praised Levy and commended in particular
his public disclosure of the case. - answers✔✔Which of the following opinions did Dr. Robert
Wachter express in his response to Paul Levy's blog about the wrong-site surgery of June 2008?
(A) Coming out with the error in public was unwise.
(B) The case was clear-cut and should not have been the subject of debate.
(C) It was a mistake not to punish staff for cutting corners and neglecting rules.
(D) Circumstances could exist where the providers were to blame for the error.
Your Answer:
The mistake should be communicated to Ben and the hospital's administrators.
The hospital should communicate right away with Ben and his family about the mistake, and
administrators also need to know about it, so they can start investigating what happened and
changing processes to avoid such an event in the future. It is likely that punishing those involved
should be avoided. Although posting information publically may be a good idea, the patient and
his family must be attended to first. - answers✔✔Ben, a 36-year-old patient with Type I diabetes
mellitus and kidney failure, comes to the hospital to have a special arteriovenous fistula placed
in his arm to allow him to begin dialysis in a few weeks. The fistula was supposed to be placed
on the left arm, but the surgical team accidentally operates on the opposite arm, not realizing
until the procedure is finished. When Ben wakes up from anesthesia, he sees a bandage on his
right arm and is confused. What should happen right away?
(A) The mistake should be communicated to Ben and the hospital's administrators.
(B) The mistake should be posted on a blog along with an explanation of the events.
(C) The entire surgical team should be reprimanded, as it was not only the responsibility of the
surgeon.
(D) All of the above
