Malpractice TBL Quiz Version 11

2. According to Reason which one of the following should be characterized as a mistake?

A. A physician ordered Flonase instead of Flovent

B. A resident ordered Naprosyn every 4 hours instead of every 12

C. A CRNA used 5,000 units of Heparin to flush an IV but had intended to use 1,000

D. A busy surgeon forgets to conduct a time-out prior to her 10th cataract surgery of the day

1. A patient with CHF is given an antibiotic in the ER. On investigation the staff reveals that at their last departmental meeting they were told they were not getting pneumonia patients antibiotics within the required 4 hour timeframe. This error is due to which system factor:

A. Team environment

B. Patient characteristics

C. Organizational/management

D. Institutional/regulatory

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