Question

Isadora is a first-year surgery resident on her first pediatric rotation. Her attending (consultant) asks her to immediately start intravenous (IV) replacement fluids on a two-year-old girl who is experiencing vomiting and diarrhea. Isadora has recently learned the guidelines for calculating fluid replacement rates for very small children; however, she confuses them and picks a rate that is too high.A. To prevent this type of error from recurring in this unit, which of the following is MOST important?B. An improved culture of safetyC. Clearer medical guidelines for fluid replacement in patients of all agesD. More severe, well-publicized consequences for providers who are recklessE. A change to the system, so that it does not rely as heavily on human memory

Answer 1

To prevent errors like Isadora's incorrect fluid replacement rates, the most important change would be creating an improved culture of safety through the use of checklists and systematic procedures that reduce reliance on memory.

Step-by-step explanation:

To prevent the type of error made by Isadora, a first-year surgery resident who confused the guidelines for calculating fluid replacement rates for children, the MOST important change would be an improved culture of safety. Machinations such as checklists have been shown to significantly reduce human error in clinical settings. A famous example is the checklist developed by Dr. Peter Pronovost, which reduced infections from central intravenous line insertions in ICUs. This approach emphasizes the importance of systematic procedures over reliance on memory or punitive measures. It encourages constant vigilance and attention to detail, with the inclusive involvement of all healthcare team members in maintaining strict adherence to safety protocols.

For Isadora's case, specific checklists for fluid replacement in pediatric patients could help ensure that correct rates are used, thereby minimizing the risk of errors like the one that occurred. This reinforces that the response to such incidents should focus on systemic improvements rather than focusing solely on individual provider penalties or just clearer guidelines.

Answer 2

A change to the system so that it does not rely so heavily on human memory

Step-by-step explanation:

The error made by Isadora is could be attributed or classed as human error because what happened to her could happen to an experienced surgeon as well. Has her error was due to confusion which could alps stem form tiredness, weariness and other personal issues. Therefore, they are several ways in which issues like these could be curtailed and prevented from reoccurring in the future. However, the most important is to perform a system change or overhaul regarding having to rely on surgeons(human) to have to calculate Recall this information in memory, rather a computerized performance of this procedure would be more reliable and less prone to confusion.