What is the most common cause of a sentinel event?

Lack of communication

Which of the following underlying causes of medical errors is described as the lack of effective "hand off" of work (e.g., transfer of medical information about a patient)?

Poor process or system design

What is the most important question you can ask when analyzing a quality or patient safety issue?

Why did the problem occur?

Which of the following is an example of lack of fail-safe methods?

Nurses not individually verifying the "five rights" of administering medications: right drug, dose, route, time and patient

What percentage of medical errors is not reported?

50-90%

patient was admitted for preterm labor, screened by RN #1 and examined by a physician. The physician gave RN #2 a verbal order for 4 gm bolus/2 gm maintenance MgSO4. RN #2 placed a large bag of MgSO4 on the IV pole and programmed the IV pump; she started the MgSO4 bolus and then was called away. Later the IV pump alarm went off and RN #1 started a second bolus. The patient complained of feeling sick but this was not addressed; the FHT alarm also was not addressed, which occurred around the time of change of shift. The physician was concerned about his order being lost during the change of shift, so he repeated the order to oncoming RN #3 but did not tell her that it was a repeat order. RN #3 gave a third bolus. Shortly after, the RNs realized that the patient had received three separate doses of 4 Gm MgSO4. All three nurses and the physician immediately went to check on the patient, and the physician ordered a stop to the MgSO4 and obtained a magnesium level. On receiving a report describing these facts, the Director of Quality Management determined that this was a sentinel event, and an interdisciplinary team was set up to look at this occurrence. In reviewing the facts of the case, what would be the major cause of the medication error?

Poor communication

Which of the following is an example of a solution to address a lack of communication?

Team building

A patient was admitted for preterm labor, screened by RN #1 and examined by a physician. The physician gave RN #2 a verbal order for 4 gm bolus/2 gm maintenance MgSO4. RN #2 placed a large bag of MgSO4 on the IV pole and programmed the IV pump; she started the MgSO4 bolus and then was called away. Later the IV pump alarm went off and RN #1 started a second bolus. The patient complained of feeling sick but this was not addressed; the FHT alarm also was not addressed, which occurred around the time of change of shift. The physician was concerned about his order being lost during the change of shift, so he repeated the order to oncoming RN #3 but did not tell her that it was a repeat order. RN #3 gave a third bolus. Shortly after, the RNs realized that the patient had received three separate doses of 4 Gm MgSO4. All three nurses and the physician immediately went to check on the patient, and the physician ordered a stop to the MgSO4 and obtained a magnesium level. On receiving a report describing these facts, the Director of Quality Management determined that this was a sentinel event, and an interdisciplinary team was set up to look at this occurrence. As a leader, what would you advise the team to do as a first step in conducting their RCA for the medication error?

Map out what happened

A patient was admitted for preterm labor, screened by RN #1 and examined by a physician. The physician gave RN #2 a verbal order for 4 gm bolus/2 gm maintenance MgSO4. RN #2 placed a large bag of MgSO4 on the IV pole and programmed the IV pump; she started the MgSO4 bolus and then was called away. Later the IV pump alarm went off and RN #1 started a second bolus. The patient complained of feeling sick but this was not addressed; the FHT alarm also was not addressed, which occurred around the time of change of shift. The physician was concerned about his order being lost during the change of shift, so he repeated the order to oncoming RN #3 but did not tell her that it was a repeat order. RN #3 gave a third bolus. Shortly after, the RNs realized that the patient had received three separate doses of 4 Gm MgSO4. All three nurses and the physician immediately went to check on the patient, and the physician ordered a stop to the MgSO4 and obtained a magnesium level. On receiving a report describing these facts, the Director of Quality Management determined that this was a sentinel event, and an interdisciplinary team was set up to look at this occurrence. After the RCA has been completed, what would contribute the most to organizational effectiveness?

Documentation and distribution of lessons learned

A patient was admitted for preterm labor, screened by RN #1 and examined by a physician. The physician gave RN #2 a verbal order for 4 gm bolus/2 gm maintenance MgSO4. RN #2 placed a large bag of MgSO4 on the IV pole and programmed the IV pump; she started the MgSO4 bolus and then was called away. Later the IV pump alarm went off and RN #1 started a second bolus. The patient complained of feeling sick but this was not addressed; the FHT alarm also was not addressed, which occurred around the time of change of shift. The physician was concerned about his order being lost during the change of shift, so he repeated the order to oncoming RN #3 but did not tell her that it was a repeat order. RN #3 gave a third bolus. Shortly after, the RNs realized that the patient had received three separate doses of 4 Gm MgSO4. All three nurses and the physician immediately went to check on the patient, and the physician ordered a stop to the MgSO4 and obtained a magnesium level. On receiving a report describing these facts, the Director of Quality Management determined that this was a sentinel event, and an interdisciplinary team was set up to look at this occurrence. In reviewing the facts of this case, what is the major implication for leadership?

Building a team to ensure the coordination of care

A patient is having shoulder arthroscopy under general anesthesia. The patient has been prepped, placed on the operating table, and Valium has already been given to the patient to relax him prior to surgery. Right before general anesthesia is to be administered, what should the operating team consider doing?

Calling a 'time out' to verify the surgical site and that this is the right patient

A patient was admitted for preterm labor, screened by RN #1 and examined by a physician. The physician gave RN #2 a verbal order for 4 gm bolus/2 gm maintenance MgSO4. RN #2 placed a large bag of MgSO4 on the IV pole and programmed the IV pump; she started the MgSO4 bolus and then was called away. Later the IV pump alarm went off and RN #1 started a second bolus. The patient complained of feeling sick but this was not addressed; the FHT alarm also was not addressed, which occurred around the time of change of shift. The physician was concerned about his order being lost during the change of shift, so he repeated the order to oncoming RN #3 but did not tell her that it was a repeat order. RN #3 gave a third bolus. Shortly after, the RNs realized that the patient had received three separate doses of 4 Gm MgSO4. All three nurses and the physician immediately went to check on the patient, and the physician ordered a stop to the MgSO4 and obtained a magnesium level. On receiving a report describing these facts, the Director of Quality Management determined that this was a sentinel event, and an interdisciplinary team was set up to look at this occurrence. What mechanism or approach would you advise the team to take?

Root-cause analysis (RCA)