SCOPE Survey
Safe Care Of Patients through Education, 2009-2010

What is the reported frequency of serious adverse events (injuries that results from medical care) among hospitalized patients in the United States?
Less than 1 percent.
1-5 percent.
6-10 percent.
More than 10 percent.

 Two different paralytic agents, one with a long half-life and the other with a short half-life, are packaged in similar glass vials with yellow caps. This is an example of:
a forcing function.
a latent error.
a medication error.
a description error.

 If the process of ordering and administering a medication has 20 steps, each with 99% accuracy, what is the likelihood of a medication error occurring each time the medication is ordered and administered?
0.2 percent.
1 percent.
2 percent.
20 percent.

 A 21 year-old college student with a documented penicillin allergy is given doxycycline for yet another episode of chlamydia. He develops a rash from the medication. This incident is best described as:
a potential adverse drug event.
a preventable adverse drug event.
a nonpreventable adverse drug event.
a latent error.

 A harried resident connects the oxygen tubing to the intravenous (IV) line of a pediatric patient who subsequently dies from a massive gas embolus. This tragedy is best described as:
a latent error.
an active failure.
a forcing function.
a knowledge deficit.

 In general, blaming the individual who makes an error does not help fix the problem or prevent it in the future. Even so, under the framework proposed by error theorist James Reason, two types of misconduct by practitioners should be punished. One is intentional injury to a patient (or anyone else, for that matter), and the other is:
injury from willful disobedience of practice guidelines.
injury from provider incompetence.
injury caused by substance abuse.
injury from violation of an unworkable rule.

 Which one of the following is the best example of an active failure?
Different chemotherapy medications with similar bottles and labeling.
An infusion pump that requires complex dosage calculations.
Scheduling residents to work more than 60 hours in a row to cover a "power weekend."
Overlooking a pneumothorax on a postcentral line chest film.

 Which one of the following is the best example of a latent error?
Ordering of a chest radiograph on the wrong patient.
Using bar codes as patient-identifiers.
Confirming a drug dose on a computerized directory.
Understaffing an intensive care unit.

 Anesthesia machines are designed so that the tube carrying the anesthetic gas physically cannot be attached to the oxygen port. What Human Factors Principle does this best exemplify?
Constraint.
Forcing function.
Reduced reliance on memory.
Elimination of look-alikes.

 A computerized medication order-entry system has been implemented which presents a limited range of doses to the ordering practitioner. What Human Factors Principle does this best exemplify?
Constraint.
Forcing function.
Simplification.
Reduced reliance on vigilance.

 Most preventable errors are caused by:
Factual deficiencies.
Process deficiencies.
Performance deficiencies.
Defensive practices.

 What are latent errors?
The injuries caused by medical management rather than the underlying disease.
The faulty interrelationships between humans, the tools they use, and the environment in which they live and work.
The unsafe acts of front-line workers.
The hidden properties of a system that permit individuals to make mistakes.

 Which one of the following is the most frequent error of daily life?
An arithmetic miscalculation.
Misreading of a label.
Forgetting to turn off a switch.
Mixing drug dosages.

 When describing how errors occur, the proximal cause refers to which one of the following?
The unsafe acts of front-line workers.
The individual responsible for the error.
The apparent reason the error was made.
The pharmaco-physiological interactions that occurred in the affected patient.


Northeastern Ohio Universities Colleges of Medicine and Pharmacy