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Each question has 5 possible answers from which to choose. Only one choice is the most correct answer. Each choice may be accompanied by an explanation.

A third-year medical student begins a rotation in internal medicine. He is instructed to arrange a CT scan of the chest for one of his assigned patients. There has been no orientation to ordering lab tests or diagnostic imaging. The student is able to locate the patient's name in the electronic medical record, but needs help finding the online CT scan requisition, and then inadvertently leaves several important fields blank. The supervising resident becomes frustrated and states out loud, "This is really simple, pay attention."

What is the term for the likely origin of the supervising resident's frustration?

A patient with leukemia correctly receives a chemotherapeutic medication which results in neutropenia. Despite appropriate precautions, an infection follows. This is a recognized inherent risk of using that medication and the possibility was discussed in the consent discussion.

What is the best next step for the healthcare providers involved? Choose the best answer.

A young woman in her first pregnancy fails to progress in the second stage of labour. She pushes for 3 hours and is tired. The obstetrician on call advises the use of forceps. Forceps delivery of the head is followed by shoulder dystocia, which is also successfully managed, and the baby is healthy. A fourth degree tear of the perineum requires repair. The patient is transferred back to her attending obstetrician for post-natal management. Neither physician discusses the tear with the patient.

The tear does not heal well. The patient complains to the provincial/territorial medical regulatory authority (College) about both the care and lack of communication.

Choose the best statement regarding disclosure with patients about harm from healthcare delivery.

A 52-year-old businessman with hypertension is seen by a surgeon for removal of an adrenal mass. The surgeon recommends a laparoscopic adrenalectomy as it is less invasive and recovery time is reduced. The possibility of laparotomy if problems are encountered is mentioned, but the implications of this are not explained. The patient signs a consent form.

Although the mass is removed successfully, significant bleeding at surgery necessitates conversion to an open procedure and also the transfusion of blood. Despite the difficulty controlling the bleeding, the surgeon does not request help from a vascular surgeon colleague who is available.

An injury to the vena cava is identified and repaired after some difficulty. At a post-operative office visit both the patient and his wife feel the surgeon did not explain what happened sufficiently. The surgeon seems dismissive of the impact of this recognized complication on his patient. A legal action follows.

What is likely the most significant issue that triggered litigation in this case?

A 55-year-old female with severe arthritis undergoes total knee arthroplasty. With the patient's knowledge, the orthopaedic resident , performs most of the procedure. In notching the femur, there is more resistance than usual, causing the saw to vibrate too much. This is likely related to the large size of the patient and extent of the arthritic condition. Excessive bone is removed. The largest available implant in the operating room does not fit perfectly.

These problems are not included in the operative note, and there is no discussion with the patient at the time. The knee dislocates 2 months later. A larger prosthesis is used in the surgical revision. This again dislocates.

The patient sees another orthopaedic surgeon who uses an X-ray to demonstrate to the patient that too much bone had been removed in the original surgery. The repeated surgeries resulted in laxity of the knee ligaments, allowing the dislocations to occur. A lawsuit follows naming the first orthopaedic surgeon, resident, and hospital.

[Ref: Case example adapted, with permission, from CRICO, the patient safety and medical professional liability provider for the Harvard medical community. Retrieved from http://www.rmf.harvard.edu/case-studies/index.aspx.]

Which one of the following likely contributed most to the decision to settle this case on behalf of the physicians?

A staff physician asks a third-year surgical resident to perform a minor surgical procedure on a ward patient. The resident almost performs the procedure on the wrong patient because there are two patients with the same name on the ward. The problem is caught in time when the patient's wrist identification band is checked.

What is the best next step?


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