step 2 ck pt safety

Patient Safety and Quality Improvement for IMGs:
High Yield Takeaways
By Edison Cano
In my last post, we started talking about the importance of PSQI. In this post, I want to emphasize
some High Yield PSQI topics and how you might see them on boards and on the wards. These are
based on the Patient Safety Primers from the Agency for Healthcare Research and Quality, if you
would like to dive deeper.
Safety Culture
Building a safety culture has become the cornerstone of PSQI, and it centers on creating and
encouraging a commitment to safety at every level. Key parts include a “blame-free”
environment, in which errors or events can be openly discussed and addressed. No yelling, no
blaming! Board questions here usually center on a mistake someone made. Look for answers that
are straightforward and unassuming. Sometimes this means admitting you made an error or
anonymously reporting an error or almost event. Be careful not to assume anything about your
team. Think twice about anything that says, “It must have been…”
Health Care-Associated Infections
Health care–associated infections (HAI) ran rampant until simple interventions decreased these
events dramatically, like washing your hands between patient encounters (which decreases the
risk for all HAI). Some examples include:
Use of clippers instead of shaving to prevent surgical site infections. Your third year surgery
clerkship is a crash-course in cosmetology.
Use of a closed urinary drainage system and catheter care, for catheter-associated urinary
tract infections.
Use of maximal sterile barrier cautions to prevent central venous catheter–related bloodstream
Semirecumbent positioning for ventilator-associated pneumonia (VAP).
These are some examples, but you can find more interventions for each HAI in the primer.
Medication Errors
Research suggests that about half of adverse drug events, resulting in over 700,000 emergency
department visits, are preventable. The basics here include:
Knowing the “Five Rights” (Administering the Right Medication, in the Right Dose, at the Right
Time, by the Right Route, to the Right Patient).
Involve a pharmacist during rounds (to prevent dosing or mixing errors)
Educate the patients about their drugs (especially anticoagulants and analgesics)
Medicine reconciliation (double checking current medication and new changes)
Don’t forget to check our post about the Official “Do Not Use” list as well.
Handoffs and Sign-outs
With current duty hour regulations and increasing shift-work, we need to provide covering
physicians with accurate patient status updates, current labs, and pending procedures to ensure
continuity of care. Events may arise from lack of communication. To prevent this, don’t forget to
Administrative data (eg, patient’s name, medical record number, and location) must be
New clinical information must be updated.

Tasks to be performed by the covering provider must be clearly explained.
Illness severity must be communicated.
Contingency plans for changes in clinical status must be outlined, to assist cross-coverage in
managing the patient overnight.
I hope you find this post useful in providing you a guide to tackling PSQI. Don’t forget to leave your
answer for the question below and any feedback in the comments!
A 73yo male patient with Alzheimer’s dementia is brought from the nursing home by ambulance
with fever and back pain. The patient has been unable to walk since a complicated knee
replacement surgery six months ago. In the patient’s chart, you find that multiple urinary catheters
have been replaced since then and nurses claim that all aseptic precautions have been followed.
Urinalysis reveals nitrites, WBCs casts, and 125,000 CFU/ml of gram negative rods are identified
later in urine culture. Which of the following could have prevented this event?
a) Avoid urinary catheter since it’s unnecessary
b) Antibiotic prophylaxis for urinary tract infections
c) Intermittent catheterization
d) Screening for treatment with scheduled urine cultures
e) Ask the patient’s family to regularly visit him


Patient Safety and Quality
Improvement for IMGs
By Edison Cano
Patient safety and quality improvement (PSQI) questions are some of the dreaded changes that
were announced for the USMLE exams months before. PSQI gained global attention several years
ago and constant research is leading to improvements in the delivery of care all around the world.
Assuring excellence in the delivery of care is paramount in medical practice and is the reason why
this dynamic field has fallen under the scope of the boards.
Learning PSQI will demand extra time for Step 2 CK and Step 3, especially for international
medical graduates. The most challenging part to studying has been finding a condensed review of
PSQI, however I want to share some basic concepts that will serve as a starting point for you to
tackle PSQI.
Patient safety events are events, incidents, or conditions that may or may not have resulted in
harm to a patient.
Adverse events are events that resulted in harm to a patient
Sentinel events are adverse events causing death, serious physical, or psychological injury, not
related to the natural course of the patient’s illness or underlying condition. They are a subset of
adverse events and are “sentinel” because they signal the need for immediate investigation and

response. Sentinel events might include:
Non-death events, which include abduction, rape, assault, suicide, or homicide of any patient
receiving care, treatment, and services (includes suicide within 72h of discharge).
Rape, assault or homicide of any visitor, vendor, or staff inside the facility during the event.
Hemolytic transfusion reaction involving major blood group incompatibilities.
Invasive procedure, including surgery, on the wrong patient, wrong site, or wrong procedure or
unintended retention of a foreign object.
Any intrapartum maternal death, unanticipated death of a full-term infant, severe neonatal
hyperbilirubinemia (bilirubin >30 ml/dl), or discharge of an infant to the wrong family.
Any delivery of radiotherapy to the wrong body region or >25% above the planned
radiotherapy dose, or a cumulative dose >1,500 rads to a single field.
A “near-miss event” is an event that did not produce patient injury; i.e. the medical error or
system failure did not reach the patient. All these events must be anonymously reported to
conduct a root cause analysis, which is intended to determine WHY this happened instead of
WHO did wrong.
I hope you find this post useful and invite you to come back for the next post about PSQI, in which
I will discuss interventions and resources. I leave you with the following question; please, don’t
forget to leave your answer in the comments below and good luck in your preparation!
Question: A 75 year-old male patient with history of hypertension and diabetes mellitus is brought
in by ambulance to the emergency department at night with altered mental status, cough, and
fever for the last two days. His wife states that the patient has become progressively lethargic. A
chest x-ray revealed a lobar condensation and patchy infiltrates diffusely distributed in both lung
fields. BP 90/55, HR 120bpm, RR 20, T° 39.8°C. The patient is admitted to the ICU, fluids and
antibiotic therapy are begun. Over the next day, his mental status improves but you notice his
hand is swollen and tender to touch, however neither the patient nor his wife recall any incident
from yesterday that could cause this finding. After asking the admitting night team, you learn that
on his way to the ICU, while turning a corner on his bed, the patient’s hand hit the wall. What is the
best next step?
a) Start a root cause analysis to prevent similar events
b) Report the event anonymously to the authorities
c) Inform the patient and his wife about the event and reassurance
d) Find the person who took the patient to the ICU to determine the course of action
e) Inform the staff and other departments in the hospital about the event to avoid further events