IHI: PS 104: Teamwork and Communication fully solved

IHI: PS 104: Teamwork and Communication Lesson 1 Referring to the video on the previous page, in your opinion, what was the underlying cause of the adverse event? -The culture of the hospital did not promote safety as the highest priority. - The surgeon failed to listen to the scrub technician student and the nurses. The charge nurse failed to insist on an X-ray. The scrub technician student and the circulating nurse failed to insist on an X-ray. The charge nurse failed to insist on an X-ray. A healthy 45-year-old athlete is scheduled for a knee arthroscopy to clean up her knee so that she can ski better in the coming winter. This is a low-risk, straightforward procedure.The chief of orthopedics will perform the procedure. After two complex and time-consuming procedures, this is his final surgery of the day.Because of a staffing issue, two nurses are pulled from another operating room (OR) to help. They are experienced nurses but have never worked in orthopedics before, and they don't know any of their colleagues.The surgery begins with limited introductions or discussion about the case, and the surgeon has loud music playing. He asks one of the two "new" nurses for 20 mL of local anesthetic with dilute epinephrine to put in the knee. The nurse hears only, "Give me the epi." Not knowing what it is for, she hands him a syringe with 20 mL of concentrated epinephrine, which is 1,000 times too much.As a result, the patient suffers a massive heart attack, a near fatal event. If the team had taken time for a short conversation prior to the procedure, what do you think they could have accomplished? - Acquainted the team members - Verified the experience and comfort level of the team members to provide the care - Identified what drugs were going to be used