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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.

An 18-year-old male is admitted to a psychiatric ward because of suicidal ideation. The attending physician orders medications and observation every 30 minutes. Overnight, the nurses observe the patient becoming increasingly agitated. They document this in the medical record. They do not convey their concerns verbally to the oncoming shift of nurses or to the physician. While making rounds, the physician does not read the nurse's notes. Later that morning the patient harms himself in his hospital room.

What system improvements might decrease the likelihood of this harmful incident recurring in the future? Choose the best answer.


A 38-year-old female who had had Roux-en-Y gastric bypass 2 years ago presents to the emergency department at night with severe abdominal pain. A junior resident notes she is afebrile and her abdomen is firm and distended with guarding and rebound. A nasogastric tube and IV analgesic provides little relief. An abdominal CT scan shows a partial small bowel obstruction and a single gallstone.

The resident calls the attending staff surgeon at home and is instructed to call the senior resident. The senior resident is in the operating room and is not available for 3 hours. The attending surgeon, hearing nothing further, assumes the senior resident is managing the patient. Surgery is significantly delayed.

The patient suffers a bowel infarction and commences a lawsuit alleging negligence (professional civil liability in Québec) in the treatment of the small bowel obstruction.

[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 statements is true? Choose the best answer.


A 30-year-old-woman G1P0 in her 41st week of gestation has mild pregnancy induced hypertension and requires induction. Early in the morning, Misoprostol is placed intravaginally. Several hours later the patient's membranes rupture. A recently graduated nurse attributes the mother's mildly elevated BP to the contractions and vomiting the patient is experiencing. A junior resident finds the cervix is 5-6 cm, 90% effaced and vertex at 0 station. An internal fetal monitor is placed.

Following an epidural, prolonged deceleration of the fetal heart rate (FHR) is observed, but this recovers with repositioning, oxygen, and intravenous fluids. The nurse notifies the resident whose demeanor is gruff, and monitoring continues. The resident does not update the staff obstetrician. FHR decelerations occur periodically.

At mid-afternoon, the nurse writes in the progress notes that the FHR is "flat, with no variability" but does not report this to the resident. A short time later the mother has the urge to push. She is fully dilated with caput at +1. Severe fetal bradycardia follows.

When vacuum and forceps delivery fails, an emergency C-section is promptly done; the baby is stillborn. Uterine rupture had occurred.

[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 contributed most to what happened in this case? Choose the best answer.


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