Avas Panel Sun

5 Questions
Avas Panel Sun

AVAS Panel Session on Never Events, Sunday, May 7, 2017

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Questions and Answers
  • 1. 
    According to the Joint Commission, which of the following is the best estimate of “wrong site” surgery being performed on a weekly basis is:
    • A. 

      One or two per week

    • B. 

      A dozen per week

    • C. 

      Approximately thirty per week

    • D. 

      Fifty per week

  • 2. 
    What is the most common type of sentinel event?
    • A. 

      Falls

    • B. 

      Medication Error

    • C. 

      Wrong site surgeries

    • D. 

      Suicide

  • 3. 
    Of the 8 expected elements of disclosure, which one(s) were most commonly omitted by surgeons in this study:
    • A. 

      Disclosure within 24 hours

    • B. 

      Facts about what happened

    • C. 

      Whether the event was preventable

    • D. 

      Steps taken to treat any subsequent problems

  • 4. 
    Patient Jane Doe undergoes a cholecystectomy for symptomatic cholelithiasis. Though the procedure began using laparoscopy, a conversion to open repair was made when an arterial branch was cut and the bleeding could not be controlled rapidly. The patient had a temporary drop in intraoperative blood pressure, but the operation was completed successfully with no further hemodynamic changes and no blood transfusion requirement. She recovered and was discharged home. Which of the following is the most appropriate response of the surgeon?
    • A. 

      Inform the patient and family that all went well and sometimes open repair is just necessary due to anatomy and other technical considerations.

    • B. 

      Inform the patient and family of the rationale (need to control bleeding) behind conversion to open repair.

    • C. 

      Inform risk management of the incident as this constitutes a “never event”.

    • D. 

      Inform the patient and family that the bleeding and need for open conversion was due to a resident’s lack of experience.

  • 5. 
    Patient John Q. Public underwent an uneventful retroperitoneal partial right nephrectomy and was discharged home on postoperative day #3. On postoperative day #7, he returned to the emergency department with a high temperature, shaking chills, back pain, and low blood pressure. After resuscitation and institution of broad spectrum antibiotics, an abdominal CT was performed. The CT revealed a radiopaque object and fluid collection in the right retroperitoneum. Incision and drainage of the abscess resulted in removal of a retained sponge (Ray-tec).Which of the following is the most likely outcome following filing of a lawsuit by the patient against the hospital and surgeon?
    • A. 

      Criminal negligence charges will be filed against the hospital and surgeon by the District Attorney.

    • B. 

      The surgeon will be deemed unsafe by the hospital and lose his/her position.

    • C. 

      The hospital and surgeon will go to court to counter the malpractice negligence claim for the retained foreign body.

    • D. 

      The paid malpractice claim will be reported to the National Practitioner Data Bank.