Patient Safety Guidelines Flashcards

A patient on warfarin is admitted for elective surgery. The INR is 3.8. The surgical team wants to proceed in 24 hours. Which bridging strategy represents best practice according to patient safety guidelines?

Answer: Hold warfarin and administer low-molecular-weight heparin until INR falls below 1.5, then discontinue LMWH 24 hours before surgery

For patients on warfarin with elevated INR requiring elective surgery, the standard bridging protocol is to hold warfarin, initiate LMWH (therapeutic dose) until the INR normalizes to below 1.5, and discontinue LMWH approximately 24 hours before surgery to reduce bleeding risk while minimizing the thromboembolic window. High-dose IV vitamin K causes unpredictable overcorrection and may make future anticoagulation difficult. FFP is reserved for emergencies, not elective procedures. Proceeding without bridging at INR 3.8 creates unacceptable hemorrhagic risk.

During a root cause analysis of a wrong-site surgery event, the team discovers that the surgical time-out was performed but the surgeon verbally confirmed the wrong side. Which systems-level failure does this MOST specifically represent?

Answer: A latent organizational failure in the verification process design allowing single-person confirmation

A root cause analysis focuses on latent systemic failures rather than individual blame. If the time-out process allowed the surgeon alone to verbally confirm the site without independent cross-verification against the marked site and consent document, the system design itself is the root failure — it created a single point of failure. This is a latent organizational error. While authority gradients, marking failures, and individual errors may be contributing factors, the deepest systems-level finding is that the verification process was not engineered to catch a single person's error.

A nurse administers a medication via the wrong route — an oral liquid is inadvertently given intravenously. The patient is harmed. Under the DHA patient safety framework, which classification BEST describes this event?

Answer: Sentinel event requiring mandatory root cause analysis and reporting to the DHA within 45 days

Under DHA patient safety regulations, a wrong-route medication error that results in patient harm meets the definition of a sentinel event — an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Sentinel events require mandatory root cause analysis and must be reported to the DHA. This is not a near-miss (harm occurred), not a simple adverse event managed internally, and the premise that oral medications are safe IV is incorrect — many oral formulations contain excipients lethal when given intravenously.

A critically ill patient in the ICU develops a central line-associated bloodstream infection (CLABSI) on day 4 post-insertion. Review shows the bundle was followed at insertion. Which ongoing maintenance factor, if absent, is MOST likely the attributable cause per evidence-based guidelines?

Answer: Failure to perform daily assessment of line necessity and delayed removal of a no-longer-indicated catheter

When insertion bundle compliance is confirmed, post-insertion maintenance failures are the primary modifiable CLABSI risk factor. The single strongest evidence-based maintenance intervention is daily assessment of line necessity and prompt removal when no longer clinically indicated — the longer a central line remains, the greater the cumulative infection risk. While lumen number, site selection, and skin prep at insertion all influence risk, the question specifies the bundle was followed at insertion, shifting causation to ongoing maintenance. Daily necessity review is specifically mandated in DHA and international CLABSI prevention bundles.

A pharmacist intercepts a prescription for methotrexate written as '7.5 mg daily' for a rheumatoid arthritis patient. The standard dosing for this indication is weekly. The prescriber insists the daily dose is intentional. What is the MOST appropriate next step under a high-reliability patient safety framework?

Answer: Escalate to the clinical pharmacist supervisor and medical director, document the clinical disagreement, and withhold dispensing until senior physician review confirms or overrides the order with documented rationale

Methotrexate daily dosing for rheumatoid arthritis is a well-documented high-alert medication error that has caused numerous fatalities — it is used weekly for RA and daily only for certain oncology indications. A high-reliability patient safety framework requires stopping the process when a high-risk discrepancy is identified, regardless of authority gradient. The pharmacist must escalate through a structured safety chain (supervisor → medical director) with documentation, and withhold dispensing until the discrepancy is formally resolved with documented clinical justification. Dispensing based on physician insistence alone, providing a partial supply without resolution, or bypassing the prescriber by contacting the patient are all unsafe approaches.

During handover in a busy surgical ward, the outgoing nurse uses SBAR to communicate about a post-operative patient. The incoming nurse reads back the critical information but mishears the urine output as '30 mL/hr' when the outgoing nurse said '13 mL/hr.' The incoming nurse documents 30 mL/hr. Which handover safety failure does this scenario MOST precisely illustrate?

Answer: Inadequate closed-loop communication — the read-back was not confirmed as accurate by the sender before the handover concluded

Closed-loop communication requires three steps: sender transmits → receiver reads back → sender explicitly confirms the read-back is correct (or corrects it). In this scenario, the read-back occurred but the loop was not closed — the outgoing nurse did not confirm the accuracy of '30 mL/hr,' allowing the error to stand. This is the precise failure: the read-back step alone is insufficient without sender confirmation. SBAR is an appropriate tool for post-operative patients. While noise and checklists are relevant, they are not the most specific failure mechanism illustrated. The root issue is an incomplete closed-loop communication process.