Note: Responses are suggested answers based on the information in the case study. Other responses may be valid.

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Question 1

Most medical errors are due to latent errors. What are latent errors?

  • Latent errors are those caused by flaws in the system, i.e., errors that lead to human (operator) errors and whose effects typically lie dormant in the system.

Question 2

Does root cause analysis (RCA) apply to near misses or only to actual adverse events?

  • RCA applies to both near misses and actual adverse events.

Question 3

RCA has several purposes. Which purpose is missing from the following list? To identify:

  1. What happened
  2. How it happened
  3. Why it happened
  • Another key purpose of RCA is to identify how to prevent errors and near misses from happening again.

Question 4

Human errors can be classified in many ways. Why is it important to classify errors into distinct categories?

It is important to classify errors into categories, since it facilitates being able to identify and compare:

  • adverse events by region, country, and even internationally

  • trends in significant types of adverse events and their causes

  • preventative measures

Question 5

Provide two main goals of risk management.

Two main goals are to:

  1. Identify circumstances that put patients at risk
  2. Prevent or control those risks.

Question 6

Why is disclosure of medical errors controversial?

  • Disclosure is controversial because it may suggest an admission of liability, making healthcare professionals and their organizations vulnerable to law suits. Nonetheless, disclosure makes sense from both ethical and quality perspectives.

Question 7

List four essential elements of negligence from a legal perspective.

Four elements of negligence are:

  1. Duty of care owed by the health professional to the patient
  2. Breach of reasonable, accepted standards of care set for the profession
  3. Injury or loss due to the breach of care
  4. Causation - the breach must be the proximate cause of the harm

Question 8

What standards of conduct are student health professionals held to legally?

  • Students are held to the same standard of conduct as practicing professionals.

Question 9

Can health professionals be held legally responsible for errors made by students they are supervising?

  • Professionals who supervise students can be held responsible for a student's errors. Supervisors have a duty to patients to provide adequate student supervision to ensure that relevant standard are met.

Question 10

Do blood safety standards include:

  1. reporting of serious adverse events?
  2. disclosure of unanticipated outcomes to patients?
  • Blood safety standards include reporting of serious adverse events but NOT disclosure of errors to patients.