USMLE New Safety Science Practice Question 2 - MUST READ !

[Focused1]

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A new intern who is not being supervised is asked to see a patient who is being discharged following treatment of a lower extremity DVT. Intern prescribes 6 month course of warfarin without reviewing the patient's other medications. Unknown to the intern the patient is on an antibiotic which increases warfarin's anticoagulation activity. The pharmacy computer system is broken and the drug is filled manually, which does not enable the computer system to alert about the interaction. an overworked nurse fails to check for drug-drug interaction and fills the order on discharge medication reconciliation. patient fills the prescription at a local drugstore and suffers a GI bleed which leads to readmission and surgery.
According to the James Ranson swiss cheese model of error, which of the following is the most effective approach to prevent this adverse event in the future ?

A. Identify and correct the single overarching failure of the healthcare system responsible for the adverse drug event.
B. Identify and weed out individuals involved in the medical error
C. Apply systematic approach to eliminate all causes of human error
D. Building successive layers of safety barriers into the system that prevent medical error from resulting in patient harm
E. Initiate campaign reminding clinicans to be more vigilant and to follow established safety protocols

 

[bobsanchez123c]

Is it d?

 

[stargazin580]

I think it's d, haha, add another cheese

 

[Macaroon_Berry]

A new intern who is not being supervised is asked to see a patient who is being discharged following treatment of a lower extremity DVT. Intern prescribes 6 month course of warfarin without reviewing the patient's other medications. Unknown to the intern the patient is on an antibiotic which increases warfarin's anticoagulation activity. The pharmacy computer system is broken and the drug is filled manually, which does not enable the computer system to alert about the interaction. an overworked nurse fails to check for drug-drug interaction and fills the order on discharge medication reconciliation. patient fills the prescription at a local drugstore and suffers a GI bleed which leads to readmission and surgery.
According to the James Ranson swiss cheese model of error, which of the following is the most effective approach to prevent this adverse event in the future ?

A. Identify and correct the single overarching failure of the healthcare system responsible for the adverse drug event.
B. Identify and weed out individuals involved in the medical error
C. Apply systematic approach to eliminate all causes of human error
D. Building successive layers of safety barriers into the system that prevent medical error from resulting in patient harm
E. Initiate campaign reminding clinicans to be more vigilant and to follow established safety protocols

where did you get these safety science practice questions from?

 

[tropocollagen]

I totally have no idea....but my guess is d. How can we prepare for this kind of questions?

 

[Transposony]

I'll go with E since both the "system" and "humans" failed in this case.

The Swiss cheese model of accident causation illustrates that, although many layers of defense lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident to occur.