Multiple Choice Questions MCQ

Question 20# Print Question

Regarding medical errors in the ED, which ONE of the following statements is TRUE?

A. Clinical risk management is a process of identifying underperforming staff in the ED

B. Cognitive errors can be reduced by implementing cognitive forcing strategies

C. The majority of medical errors in the ED are unpredictable, and therefore unpreventable

D. Root cause analysis (RCA) is a systematic process to identify those responsible for errors at each phase of the patient journey

Answer: B: Medical errors are a ‘failure of a planned action to be executed as intended (error of execution)’ or ‘use of a wrong plan to achieve an aim (error of planning)’. In international studies, approximately one in 10 patients admitted to hospital experienced an adverse event, of which half were due to medical errors. The majority of these occurred within 24 hours of arrival to hospital.

Factors specific to the ED increase the possibility of medical error – relating to staff, clinical situation, physical environment (including overcrowding), and complex interactions with multiple other systems. Areas of error, rather than being unpredictable, occur at points found repeatedly across EDs:

Patient identification errors
Triage-related errors
Hospital-acquired infections
Delays and misinterpretation of radiology and pathology tests
Medication errors
Communication errors (at handover, admission or discharge)

The majority of errors result in minor or no harm to the patient. However, since these ‘near misses’ are valuable in identifying weak points in a system, an effective incident reporting system should be part of a ED clinical risk management (CRM) system, which contributes to CQI programs.

More than 30 cognitive (thinking) and affective (emotional) dispositions have been recognized as contributing to imperfect decision making in emergency clinicians. A number of strategies have been identified to counteract these, including cognitive forcing – reducing potential to make wrong decisions, and reducing alternatives to correct decisions. It is recognized that incidents are often due less to individual poor performance of staff, but rather to an accumulation of multiple gaps in the healthcare system as in Reason’s Swiss-cheese model.

RCA is a component of CRM systems. It is a systematic process of examining an adverse event, following the care of a patient at each phase of their journey through and beyond the ED, and examining why failures of care occurred rather than apportioning blame.

References:

Sprivulis P. Patient safety. In: Cameron P, Jelinek G, Kelly A, et al, editors. Textbook of adult emergency medicine. 3rd ed. Sydney: Churchill Livingstone Elsevier; 2009. p. 806–9.
Vinen John. Clinical risk management in the emergency department. In: Cameron P, Jelinek G, Kelly A, et al, editors. Textbook of adult emergency medicine. 3rd ed. Sydney: Churchill Livingstone Elsevier; 2009. p. 840–7.
Reason J. Human error: models and management. BMJ 2000;320:768–70.

Question 16# Regarding short stay units (SSUs), which ONE of the following statements is TRUE?
A. Units are best managed by dedicated staff under the direction of an inpatient clinician
B. SSUs are ideally managed under the care of the general pool of ED nurses
C. SSUs reduce access block by admitting patients until a ward bed is made available
D. Patients admitted overnight awaiting inpatient review become the responsibility of the accepting specialty
Answer: B: SSUs, observation wards, or clinical decision units are a recent development within emergency medicine, in which selected populations of patients are admitted to an area adjacent to the ED and under the control of ED senior staff for a specified period of time (usually <24 hours). While having dedicated staff promotes consistency of practice, rotating ED nursing staff through the unit promotes skill maintenance and establishes the unit as a part of the broader ED. Decisions regarding admission should be coordinated by a single senior emergency clinician. Using the SSU as a strategy for managing access block runs the risk of spreading the block to this area and impairing the ability of the unit to function. Patients being transferred to the unit should have a defined condition or management protocol, including a specific end point at which the patient is to be admitted or discharged. Primary responsibility for patients within the ED remains with the emergency clinician responsible for the department until they are physically transferred to another clinical area and handed over. References: Australasian College for Emergency Medicine. S18: Statement on responsibility for care in emergency departments. Online. Available at: http://www.acem.org. au/media/policies_and_guidelines/responsibility_care.pdf; 5 Jun 2009. Williams A. Emergency department observation wards. In: Cameron P, Jelinek G, Kelly A, et al, editors. Textbook of adult emergency medicine. 3rd ed. Sydney: Churchill Livingstone Elsevier; 2009. 26(6) p. 800–2.

Question 17# Regarding observation medicine (OM), which ONE of the following statements is TRUE?
A. Patients with complex medical issues can have their care initiated in a protocol-driven environment
B. Effective OM is dependent on regular daily ward rounds by senior clinicians
C. Observation wards should have preferential access to diagnostic facilities
D. Exclusions should include patients requiring input from multiple allied health workers such as physiotherapy, hospital in the home or community mental health
Answer: C: Observation medicine is a model of care within the discipline of emergency medicine for patients requiring an extension of traditional ED services. Key principles specific to the model include: Early access to diagnostics, specialist advice, observation and reassessment to inform rapid decision-making and treatment Evidence-based pathways and protocols to guide delivery of care and reduce variation Collaboration between multidisciplinary clinicians and specialists with external stakeholders such as GPs or community service providers Efficiency in streamlining the care of selected patients, reducing service duplication and avoidable use of inpatient resources Units depend on frequent patient review promoting rapid decision making. As such, they require the regular or ongoing presence of experienced emergency clinicians. Coordination of support services can be cohorted in this setting. Complex patients with multiple problems are not appropriate for this setting due to the workload involved. Reference: Williams A. Emergency department observation wards. In: Cameron P, Jelinek G, Kelly A, et al, editors. Textbook of adult emergency medicine. 3rd ed. Sydney: Churchill Livingstone Elsevier; 2009. 26(6) p. 800–2.

Question 18# Which ONE of the following patients is appropriate for admission to an SSU?
A. A 32-year-old man recovering from sedation for reduction of a shoulder dislocation
B. A 18-year-old girl with diabetic ketoacidosis
C. A 65-year-old man with an infective exacerbation of chronic obstructive pulmonary disease (COPD)
D. A 22-year-old woman with recurrent pneumothorax post-aspiration
Answer: A: A post-sedation patient has a stable condition with anticipated complete resolution within a defined time period. Patients with diabetes will require ongoing monitoring and regular blood investigations. The COPD patient, if requiring admission, is unlikely to recover to discharge status within an appropriate time period. Recurrent pneumothorax will require insertion of a chest drain and subsequent medical admission for over 24 hours. Reference: Williams A. Emergency department observation wards. In: Cameron P, Jelinek G, Kelly A, et al, editors. Textbook of adult emergency medicine. 3rd ed. Sydney: Churchill Livingstone Elsevier; 2009. 26(6) p. 800–2.

Question 19# Regarding privacy and confidentiality, which ONE of the following statements is TRUE?
A. Emergency clinicians operate under an obligation to provide all requested information to police services
B. Patients have a legal right to access specialist opinions on their care, unless the report states specifically that it is not to be shown to the patient
C. In order to obtain access to personal records, a patient must explain the reason for the request
D. Patient consent is required if transferring health information from Australia to a country without similar privacy or data protection laws
Answer: D: Australian privacy legislation is controlled by a federal Act which defines 10 national privacy principles: Collection – only data required to assist healthcare is collected. Use and disclosure – patients should receive an explanation of how data may be used or disclosed to a third party. • Data quality – steps must be taken to ensure data collected is accurate and secure. Data security – data must be safe from loss, corruption, or unauthorized access. • Openness – an explanation should be provided as to how data is handled. Access and correction – patients have a right to access and correct their records. This does not mean that they have the right to read their notes or results on demand or without medical explanation, as misinterpretation or poor comprehension may be detrimental to their physical or mental well-being. However, patients do not have to provide a reason for their request, and have a right of access even if the report specifies otherwise. Identifiers – hospitals must have unique identifiers for each patient. Anonymity – where practicable, patients should have to option of accessing healthcare services without identifying themselves. • Trans-border data flows – obligations exist when transferring health information to other countries. Sensitive information – health data should not be collected or shared without the patient’s consent, except in some situations where required by law such as where there is a potential risk to the patient or others, or in the investigation of a criminal act. Similar legislation exists in New Zealand and the United Kingdom. Reference: Yuen A. Privacy and confidentiality. In: Cameron P, Jelinek G, Kelly A, et al, editors. Textbook of adult emergency medicine. 3rd ed. Sydney: Churchill Livingstone Elsevier; 2009. 25(4) p. 771–5.

Question 20# Regarding medical errors in the ED, which ONE of the following statements is TRUE?
A. Clinical risk management is a process of identifying underperforming staff in the ED
B. Cognitive errors can be reduced by implementing cognitive forcing strategies
C. The majority of medical errors in the ED are unpredictable, and therefore unpreventable
D. Root cause analysis (RCA) is a systematic process to identify those responsible for errors at each phase of the patient journey
Answer: B: Medical errors are a ‘failure of a planned action to be executed as intended (error of execution)’ or ‘use of a wrong plan to achieve an aim (error of planning)’. In international studies, approximately one in 10 patients admitted to hospital experienced an adverse event, of which half were due to medical errors. The majority of these occurred within 24 hours of arrival to hospital. Factors specific to the ED increase the possibility of medical error – relating to staff, clinical situation, physical environment (including overcrowding), and complex interactions with multiple other systems. Areas of error, rather than being unpredictable, occur at points found repeatedly across EDs: Patient identification errors Triage-related errors Hospital-acquired infections Delays and misinterpretation of radiology and pathology tests Medication errors Communication errors (at handover, admission or discharge) The majority of errors result in minor or no harm to the patient. However, since these ‘near misses’ are valuable in identifying weak points in a system, an effective incident reporting system should be part of a ED clinical risk management (CRM) system, which contributes to CQI programs. More than 30 cognitive (thinking) and affective (emotional) dispositions have been recognized as contributing to imperfect decision making in emergency clinicians. A number of strategies have been identified to counteract these, including cognitive forcing – reducing potential to make wrong decisions, and reducing alternatives to correct decisions. It is recognized that incidents are often due less to individual poor performance of staff, but rather to an accumulation of multiple gaps in the healthcare system as in Reason’s Swiss-cheese model. RCA is a component of CRM systems. It is a systematic process of examining an adverse event, following the care of a patient at each phase of their journey through and beyond the ED, and examining why failures of care occurred rather than apportioning blame. References: Sprivulis P. Patient safety. In: Cameron P, Jelinek G, Kelly A, et al, editors. Textbook of adult emergency medicine. 3rd ed. Sydney: Churchill Livingstone Elsevier; 2009. p. 806–9. Vinen John. Clinical risk management in the emergency department. In: Cameron P, Jelinek G, Kelly A, et al, editors. Textbook of adult emergency medicine. 3rd ed. Sydney: Churchill Livingstone Elsevier; 2009. p. 840–7. Reason J. Human error: models and management. BMJ 2000;320:768–70.

Your-Doctor Multiple Choice Questions (MCQ)

Your-Doctor
Multiple Choice Questions (MCQ)