IHI PS 105 - Responding to Adverse
Events Post lesson assessments 1-3
When an error occurs, which of the following is generally the proper order of
prioritization? - CORRECT ANSWER-Care for the patient, communicate with the
patient, report to all appropriate parties, check the medical record.
The first priority is to address the current health care needs of the patient. After
caring for the patient's immediate clinical needs, start preparing for the initial
communication session with the patient and/or the patient's representative. Various
people, departments, entities, or agencies may need to be notified that there has
been an adverse event, so once the immediate patient needs are addressed, you'll
want to make sure the proper parties are informed. The last concern is making sure
the medical record contains a complete, accurate record of the clinical information
pertaining to the unanticipated adverse outcome.
If you are responsible for the initial communication with a patient about an error,
which of the following should you be sure to do? - CORRECT ANSWER-Let the
patient and family know who is available to help them.
It is important to acknowledge that the event occurred and to make it clear who will
be available to help the patient and family. You probably don't know exactly what
caused the error at the time of the initial communication, but that's OK. Rather than
completely disguising your feelings, you should express empathy and compassion.
Which of the following is true regarding communication about adverse events with
patients? - CORRECT ANSWER-In some cases, the care team may decide for
medical reasons to defer communication with a patient about an upsetting incident.
Patients have a right to know what happened in their care, and not having all the
facts is not a reason to delay communication; just share what you know. Training in
communication is helpful, but communicating after an adverse event is not unduly
complex, and it should be done by those directly involved in the incident.
Janice is a nurse on the orthopedics unit. This night, she is caring for five patients,
as well Janice is a nurse on the orthopedics unit. This night, she is caring for five
patients, as well as a new admission from the emergency department. While juggling
patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who
is in significant pain from a fractured hip. Janice hastily writes down the morphine
order from the resident and is then called away when another patient falls out of bed.
, An hour later, she realizes, to her dismay, that she has not yet given Mrs. Bernardo
her pain medication. When she rushes into the room, the patient is crying and
asking, "Why won't someone help me?" Janice quickly administers the morphine.
When discussing the event a little while later with Mrs. Bernardo, the most
appropriate initial comment would be: - CORRECT ANSWER-"How is your pain?"
The first and most important issue when a patient receives less than ideal care is to
make sure you stabilize and care for the patient. Only after the patient's safety and
comfort are addressed should you consider an apology.
Your organization has a voluntary reporting system for errors. Which of the following
incidents should you report? - CORRECT ANSWER-Both of the incidents above
The best answer is both of the incidents. When people report errors, whether they
have negative consequences or not, organizations can learn from them. It is your job
to report the errors you experience, and the organization's job to decide which ones
are the highest priority for action.
When giving an explanation for why an event happened, it is always important to: -
CORRECT ANSWER-Be factual.
Explanations may mitigate or aggravate the patient's feelings about an event, but
they should be factual. Although you may sometimes want to discuss things with the
risk management department or bring documents, these actions are not always
needed or appropriate.
When giving an explanation for why an adverse event happened, it can sometimes
be a good idea to: - CORRECT ANSWER-Say something like, "There is just no
excuse for what happened."
Sometimes the statement "There is no excuse for what happened," can be the most
honest and dignified explanation at the time of your initial apology. Explanations may
mitigate or aggravate the patient's feelings about an event, but they should be
factual. The speaker must make it very clear that the patient did not do anything
wrong.
According to researchers, which of the following is a common reason why caregivers
choose not to communicate when something bad happens? - CORRECT
ANSWER-They fear disapproval.
In the paper discussed in this lesson, published by Banja and colleagues, there were
many reasons why providers found it challenging to communicate with patients and
families after adverse events, many of which related to fear — fear of disapproval,
Events Post lesson assessments 1-3
When an error occurs, which of the following is generally the proper order of
prioritization? - CORRECT ANSWER-Care for the patient, communicate with the
patient, report to all appropriate parties, check the medical record.
The first priority is to address the current health care needs of the patient. After
caring for the patient's immediate clinical needs, start preparing for the initial
communication session with the patient and/or the patient's representative. Various
people, departments, entities, or agencies may need to be notified that there has
been an adverse event, so once the immediate patient needs are addressed, you'll
want to make sure the proper parties are informed. The last concern is making sure
the medical record contains a complete, accurate record of the clinical information
pertaining to the unanticipated adverse outcome.
If you are responsible for the initial communication with a patient about an error,
which of the following should you be sure to do? - CORRECT ANSWER-Let the
patient and family know who is available to help them.
It is important to acknowledge that the event occurred and to make it clear who will
be available to help the patient and family. You probably don't know exactly what
caused the error at the time of the initial communication, but that's OK. Rather than
completely disguising your feelings, you should express empathy and compassion.
Which of the following is true regarding communication about adverse events with
patients? - CORRECT ANSWER-In some cases, the care team may decide for
medical reasons to defer communication with a patient about an upsetting incident.
Patients have a right to know what happened in their care, and not having all the
facts is not a reason to delay communication; just share what you know. Training in
communication is helpful, but communicating after an adverse event is not unduly
complex, and it should be done by those directly involved in the incident.
Janice is a nurse on the orthopedics unit. This night, she is caring for five patients,
as well Janice is a nurse on the orthopedics unit. This night, she is caring for five
patients, as well as a new admission from the emergency department. While juggling
patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who
is in significant pain from a fractured hip. Janice hastily writes down the morphine
order from the resident and is then called away when another patient falls out of bed.
, An hour later, she realizes, to her dismay, that she has not yet given Mrs. Bernardo
her pain medication. When she rushes into the room, the patient is crying and
asking, "Why won't someone help me?" Janice quickly administers the morphine.
When discussing the event a little while later with Mrs. Bernardo, the most
appropriate initial comment would be: - CORRECT ANSWER-"How is your pain?"
The first and most important issue when a patient receives less than ideal care is to
make sure you stabilize and care for the patient. Only after the patient's safety and
comfort are addressed should you consider an apology.
Your organization has a voluntary reporting system for errors. Which of the following
incidents should you report? - CORRECT ANSWER-Both of the incidents above
The best answer is both of the incidents. When people report errors, whether they
have negative consequences or not, organizations can learn from them. It is your job
to report the errors you experience, and the organization's job to decide which ones
are the highest priority for action.
When giving an explanation for why an event happened, it is always important to: -
CORRECT ANSWER-Be factual.
Explanations may mitigate or aggravate the patient's feelings about an event, but
they should be factual. Although you may sometimes want to discuss things with the
risk management department or bring documents, these actions are not always
needed or appropriate.
When giving an explanation for why an adverse event happened, it can sometimes
be a good idea to: - CORRECT ANSWER-Say something like, "There is just no
excuse for what happened."
Sometimes the statement "There is no excuse for what happened," can be the most
honest and dignified explanation at the time of your initial apology. Explanations may
mitigate or aggravate the patient's feelings about an event, but they should be
factual. The speaker must make it very clear that the patient did not do anything
wrong.
According to researchers, which of the following is a common reason why caregivers
choose not to communicate when something bad happens? - CORRECT
ANSWER-They fear disapproval.
In the paper discussed in this lesson, published by Banja and colleagues, there were
many reasons why providers found it challenging to communicate with patients and
families after adverse events, many of which related to fear — fear of disapproval,
