Step Inside the Patient Safety Horror Room

Ryan Syrek, MA


January 25, 2019

Some of the risks and dangers the room highlights are not easily shown here, such as the lack of deep venous thrombosis prophylaxis and pressure ulcer risk. Other dangers are immediately obvious, like this broken hand sanitizer.

Here are the four errors you should have noticed from the preceding pictures:

Horror 1 - The protective bed rail is down, representing a falling danger.

Horror 2 - Latex gloves are on the bedside table. The patient is allergic to latex.

Horror 3 - The patient is being administered penicillin but is allergic.

Horror 4 - The bag is also labeled with a different patient's name.

The simulation also asks trainees to identify "cost hazards" in an effort to place emphasis on awareness and overuse during residency. An unnecessary catheter and hand restraints are examples of what trainees are challenged to find. The University of Chicago hopes that this room filled with faux horrors helps the doctors of tomorrow avoid them when lives are on the line.


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