Anatomy of a lawsuit

Knowledge Check

1. A pediatrician is served with a Statement of Claim alleging a delay in the diagnosis of sepsis
in a young infant.
What is his BEST next step?
a. Call the patient’s parents to dissuade them from proceeding with the legal action.
b. Discuss the case with his colleagues to get their opinion.
c. Call the CMPA.
d. Call the family’s lawyer to clarify the situation.

The correct answer is C. When a physician is served with a Statement of Claim, they
should contact the CMPA first, as soon as possible for advice and support. It is important
that the physician not contact any of the defendants or their legal counsel, or discuss
details of the case with colleagues without first speaking with CMPA.

2. The wrong kidney is removed from a patient who was the main income earner for her family.
She subsequently requires dialysis and a kidney transplant. She commences a legal action
alleging negligence (fault in Québec), by the hospital and the surgeon for removing the wrong
kidney. The surgeon is personally given a copy of the Statement of Claim, where she is named
as one of the defendants.
What is the next stage in the legal process for the surgeon and her lawyer? Choose the BEST
answer.
a. Meet with a neutral party to discuss whether there was a breach of the standard of
care by the surgeon and/or hospital.
b. Ignore the Statement of Claim to ensure no judgment is rendered against the
surgeon and destroy any copies of the Claim in the surgeon’s possession.
c. Canvass other members of the healthcare team to discuss why the wrong kidney
was removed before addressing the Statement of Claim.
d. Prepare a Statement of Defence based on the surgeon’s recollection of the events,
original medical record, reports, and hospital records.

The correct answer is D. The surgeon and her lawyer would prepare a Statement of
Defence based on the surgeon’s recollection of the events, medical records, and any
available reports.
3. An emergency physician discharges a patient from the emergency department after
evaluating him for chest pain. The patient returns the next day and is diagnosed with an acute
myocardial infarction. A legal action follows, alleging that the delay in diagnosis was the result
of negligent care by the emergentologist.
The expert opinions of other emergency physicians are sought. Which of the following
statements regarding medical experts is MOST correct?
a. Medical experts assist the court in determining issues outside the court’s direct
knowledge, such as what would constitute a reasonable standard of knowledge and
skill in a particular circumstance.
b. Experts testifying in court must always be physicians.
c. The medical experts’ duty is to advocate for the party who hires them.
d. The training and clinical work of the medical expert are not pertinent.

The correct answer is A. In order to assist the court in determining what constitutes a
reasonable standard of knowledge and skill in a particular circumstance, medical experts
have a duty to be impartial and objective. Experts on standard of care are generally of
similar training and experience as the defendant physician.

4. A lawyer asks you to provide an expert opinion on a case. You have the necessary time
and qualifications to act as an expert and are interested in doing so.
What is your BEST next step?
a. Ask the lawyer what opinion she would like you to provide.
b. Carefully review the documentation provided and give an unbiased opinion.
c. Call the CMPA to seek its permission to act as an expert witness.
d. Call the physician involved in the case to determine his side of the story.

The correct answer is B. Medical experts have a duty to provide an unbiased opinion of
the facts, even if it is not helpful to the party’s case.

5. A 43-year-old patient presents to the emergency department with a sudden, severe

headache. It takes time to make the diagnosis of subarachnoid hemorrhage. The patient is left
with permanent right-sided weakness and initiates a legal action, which is defended through
trial.
Which of the following is the strongest rationale for defending the legal action through trial?
a. The plaintiff accepted the mediated resolution.
b. The defendant had no expert support for the care given by the physician.
c. Both the plaintiff and the defendant had good expert support for their respective
positions.
d. A pre-trial judge recommended the action be settled by the defendant.
The correct answer is C. The strongest rationale for defending the legal action through
trial is that both the plaintiff and the defendant have good expert support for their respective
positions.
 Delegation & supervision
Knowledge Check

1. A 6-week-old infant presents with fever in the emergency department (ED). You believe she
needs to undergo a lumbar puncture to rule out meningitis. You are working with a third-year
pediatrics resident whom you have not previously met. She tells you that she has been “signed
off” on the entrustable professional activity (EPA) of performing a lumbar puncture.
What is your BEST next step as it pertains to your decision to delegate the lumbar puncture to
the resident?
a. You can delegate the task since a third-year pediatrics resident should have the
necessary knowledge and skills to do a lumbar puncture.
b. You can delegate the task if the resident tells you they are comfortable doing it.
c. You can delegate the task because she has been deemed competent for that EPA
by her program.
d. You can delegate the task if, after a discussion with her, you believe she possesses
the required knowledge and skills to perform it safely.

The correct answer is D. Supervisors need to assess a trainee’s knowledge, skills, and
experience in order to appropriately delegate and decide on the level of supervision
required.

2. A staff internist is caring for a patient with a malignant pleural effusion. She delegates the
insertion of the chest tube to the senior resident, with whom she has previously worked and
whose skills she has previously assessed. The resident accepts to perform the task and knows
that the staff will be available in-house PRN. Unfortunately, the patient experiences a
hemothorax and subsequently dies.
What statement describes a judge’s MOST LIKELY assessment about the delegation of the
task?
a. The resident should have told the internist it was unreasonable to expect them to insert
the chest tube.
b. The internist appropriately delegated the insertion of the chest tube to the senior
resident.
c. No formal supervision was required if the resident had passed that entrustable
professional activity.
d. The internist should have supervised the resident in person.
 The correct answer is B. The internist appropriately delegated the insertion of the chest
tube to the senior resident, whose knowledge, skills, and experience she knew well.

3. An emergency physician is working with a resident during his day shift and decides to let her
discharge patients prior to reviewing them with him.
Which statement BEST justifies the attending physician’s decision?
a. The resident has uniformly been deemed to have stellar judgment by all other
attendings.
b. The resident has expressly stated that she wishes to have a high level of autonomy
as a “stretch goal” during her rotation.
c. The resident is in her final year of training and has to learn to make independent
decisions.
d. The emergency physician has previously worked with the resident and understands
her abilities, trusts her insight, and deems her ready to do so.

The correct answer is D. As a supervisor, the emergency physician assesses the

residents’ knowledge, skills, and experience, to establish the required level of supervision.

4. A second year family medicine resident has worked in a dermatologist’s clinic for the past 3
months. She sees a 28-year-old patient who presents with a left cheek lesion suspicious for
melanoma. She is hoping that the staff physician will let her perform the procedure since she
has had some experience with local biopsies, but the dermatologist insists that she will be
performing the procedure herself.
Which of the following would be the most acceptable and BEST explanation for this decision?

a. The staff has greater experience, which will optimize the likelihood of having clear
margins with the smallest possible scar.
b. The staff could not bill for the excision if the resident did it.
c. The resident has already done many such procedures and does not need more
experience.
d. The staff can do the procedure more quickly than the resident.

The correct answer is A. The patient’s best interests guided the dermatologist’s decision.
It is her prerogative to decide who is best placed to provide the best possible outcome for
the patient.

5. A senior resident is keen to empower her team and to be there to support individual
members of the team when she is on-call.
As it pertains to the safety of delegating tasks to junior residents, which approach is MOST
likely to promote safe care?
a. She should tell her team to always call her to review their decisions.
b. She should tell her team that she trusts them to do the right thing and not to worry
about calling her for “every little thing.”
c. She should hold a team huddle at the beginning of her shift where she normalizes
knowledge gaps and encourages her team to speak up about any concerns they
have.
d. She should ask the nurses on the unit to watch the juniors and “show them how it’s
done.”

The correct answer is C. By creating an atmosphere where people are allowed to voice
concerns and be vulnerable, the resident promotes psychological safety and will increase
the likelihood that her team will call her when they need her.
 Documentation
Knowledge Check

1. You have recently completed a complicated clinical assessment for a patient who did not
speak your language and whose diagnosis is not yet clear.
Which statement is correct about your clinical note?
a. The entry should be done as soon as practically possible after the patient encounter.
b. You do not need to acknowledge what the nurse has already documented in his
notes, including vital signs.
c. The fact that an interpreter was present to obtain the patient’s history does not need
to be documented.
d. It is sufficient to document that the patient should follow up PRN (as the occasion
arises).

The correct answer is A. Documenting your medical record entries as soon as practically
possible after the patient encounter allows you not to forget important details from your
assessment, and may trigger you to identify missing information you may want to obtain.

2. You diagnose a cellulitis in a patient seen in the emergency department and prescribe an
antibiotic to be taken as an outpatient. The patient’s condition quickly deteriorates. She is
diagnosed with necrotizing fasciitis 24 hours later by another physician. A lawsuit is filed
against you, alleging you were negligent in that you did not provide adequate discharge
instructions to your patient.
Which of the following elements of proof is the BEST to demonstrate your diligence?
a. The opinion of medical experts about what instructions you should have provided.
b. The patient’s written recollection of the instructions you gave her.
c. The discharge instructions recorded on the emergency department chart.
d. Your testimony about the usual instructions you provide to patients with cellulitis.

The correct answer is C. The medical record is usually considered to be the most
important evidence in a legal action.

3. A 60-year-old male undergoes an elective laparoscopic cholecystectomy. The surgeon has

considerable difficulty in recognizing the common bile duct from the cystic duct during the
operation. After some minutes, the cystic duct is finally isolated to the surgeon’s satisfaction
and clipped.
The BEST approach for documenting the issue in your operative note is:
a. Avoid mentioning the difficulty in identifying the anatomical structures because this
entry may cause a medical-legal problem if a complication later arises.
 b. Avoid mentioning the difficulty with the anatomical structures as this could call the
competency of the surgeon into question.
c. Mention the difficulty in identifying the anatomical structures, as this may be helpful
later in caring for the patient if complications occur.
d. Mention the difficulty in identifying the anatomical structures, to help in departmental
quality improvement (QI) audits.

The correct answer is C. It is important to include a reference to issues that arise during
surgery to establish the context and rationale for the decisions made.

4. You are a consultant for a patient with a complex medical condition. Many other consultants
are involved in the care as well, and you disagree with one of your colleagues’ impression and
treatment suggestions.
Which of the following statements BEST reflects your approach to documentation?

a. You should not write a conflicting opinion, for fear of creating confusion within the
team.
b. You should document your differing opinion and suggestions in an objective and
factual manner.
c. You should cross out your colleague’s opinion and write a comment as to why you
are critical of their opinion.
d. You should speak to your colleagues before committing to an opinion on paper.

The correct answer is B. Documenting your opinion about investigations or treatment

plans for patients in a professional and factual manner is important, even if your opinion
differs from a colleague.

5. A regulatory authority (College) is investigating a patient complaint about the quality of a

physician’s care. The investigation includes a review of the medical record.
What element pertaining to the medical record is the College MOST LIKELY to find to
represent unprofessional behaviour?
a. An incorrect entry being crossed out, with an accompanying date and signature.
b. An entry being modified the week after the College sent notice of the complaint to
the physician.
c. A signed and dated addendum to the medical record to clarify an unexpected
outcome.
d. The inclusion of a differential diagnosis in an assessment.
The correct answer is B. It is important not to alter any part of the medical record once
you are notified of a legal action or College complaint.
 Informed Consent
Knowledge Check

1. A third-year pediatrics resident speaks to the parents of a 6-week-old infant with suspected
meningitis. The resident recommends that the baby undergo a lumbar puncture. During the
consent discussion, the parents ask who will be doing the procedure.
Which statement represents the resident’s BEST next step?
a. She should tell the parents that she will be doing the procedure and reassure them
that she has done several in the past.
b. She should tell the parents that she is a resident and that she will be doing the
procedure with the attending physician available in the department as needed.
c. She should explain to the parents that she is a physician undergoing specialty
training who works under the supervision of a more experienced physician and that
she plans to do the procedure, with their permission.
d. She should ask the parents whether they would agree to her doing it.

The correct answer is C. The resident should explain that she is a physician undergoing
specialty training who works under the supervision of a more experienced physician, and
that she would like to do the procedure with their consent.

2. You are the attending physician in an emergency department where a 94-year-old female
with acute respiratory failure is transferred by ambulance from home. She is unable to
communicate coherently. There is no advance medical directive and she is unaccompanied by
family.
Which of the following is the BEST option concerning initiating treatment?
a. You should seek consent from an appropriate substitute decision-maker before
initiating treatment.
b. You should treat her immediately despite the lack of consent because this is a life-
threatening condition.
c. You should withhold aggressive treatment until the patient’s code status is
determined.
d. You provide comfort care as resuscitation is likely to be medically futile.

The correct answer is B. In life-threatening situations, where the patient is unable to

consent and the substitute decision-maker is not available, a physician may do what is
immediately necessary to appropriately treat the patient, while respecting any previously
known wishes of the patient. Consent should be obtained as soon as reasonably possible.
3. A 13-year-old female visits her family physician seeking the birth control pill. She admits to
contemplating sexual involvement with her 13-year-old boyfriend.
Which of the following statements is MOST correct about the patient’s capacity to consent?
a. The physician must determine whether the patient is capable of consenting.
b. The patient’s parents can deem her capable of consenting to the treatment.
c. The patient is not capable of consenting because she is not a mature minor (or has
not reached the age of 14 in Québec).
d. The patient must first demonstrate sound decision-making abilities before being
deemed capable of consenting.

The correct answer is A. The physician has the responsibility to assess the capacity of
any patient every time a treatment is proposed. Capacity may be presumed unless there
are features suggesting an inability to understand the nature of the treatment and its
reasonably foreseeable consequences

4. A judge in a civil action for alleged medical negligence must decide whether the defendant
physician met the standard of care in obtaining informed consent for a treatment that resulted
in a severe complication.
Which of the following statements regarding informed consent is MOST correct?

a. Judges generally have great sympathy for busy physicians who fail to have an
informed consent discussion with patients due to lack of time.
b. A signed and witnessed consent form does not constitute evidence that an adequate
consent discussion took place.
c. When there is disagreement between the physician and patient over what was said
during a consent discussion, judges will usually accept the physician’s account of
the events.
d. A physician’s testimony about their “usual practice” with respect to informed consent
discussions will generally be regarded by judges as having as much evidentiary
weight as a contemporaneous note in the medical record.

The correct answer is B. Consent is a process. Documentation of an adequate consent

discussion includes a description of the procedure, of its alternatives, and of the risks
discussed. Documenting questions asked by the patient also personalizes the
documentation and gives it credibility. A signed consent form is generally required by
hospital policy, but is not adequate evidence of the consent discussion.

5. A patient with a history of uterine fibroids and dysmenorrhea is seeking care from a
gynecologist about options to treat her chronic pelvic pain.
What statement BEST represents the approach of the surgeon in order to ensure the patient
makes an informed decision?
 a. The surgeon should provide the patient with such information as a reasonable
patient in similar circumstances would want to know.
b. The surgeon should provide the patient with such information as a reasonable
physician in similar circumstances would consider appropriate to disclose.
c. The surgeon should conduct the consent discussion in the presence of a witness.
d. The surgeon should include information about the option to undergo experimental
therapies.

The correct answer is A. When seeking consent from a patient for an investigation or
treatment, physicians are expected to provide patients with the information that a
reasonable patient in similar circumstances would want to know.
 Informed Discharge
Knowledge Check

1. A 40-year-old female presents to the emergency department with a severe asthma attack
and is treated with steroids. Her breathing improves and she is discharged home, with
prescriptions for salbutamol and inhaled corticosteroids.
Which statement BEST represents the information that should be included in a discharge
discussion?
a. A comprehensive overview of the risks and benefits of steroid therapy.
b. Only the most common and most serious side effects of steroid therapy.
c. The signs and symptoms that would indicate a deterioration in her condition or a
side effect of the medications prescribed.
d. Advice on the long-term management of asthma.

The correct answer is C. When discharging patients, it is important to inform them about
the signs and symptoms that would enable them to detect an important side effect or a
worsening condition and to provide guidance on the urgency with which to seek care and in
which setting (i.e. emergency department or office).

2. A 22-month-old infant presents to a family physician’s office clinic with a history of vomiting
and diarrhea. After a thorough assessment, the physician determines that the child is well
enough to be managed at home. The physician would like to delegate the provision of discharge
instructions to someone else on his team.
Which of the following statements BEST summarizes the guiding principles for delegating the
discussion?
a. The office receptionist may hold the discussion because she will be receiving calls
for help from the patient.
b. The office nurse may hold the discussion because she has sufficient experience,
skill and knowledge to do so.
c. The physician cannot delegate the informed discharge discussion to anyone else.
d. A well-crafted, easy-to-read handout outlining the signs of dehydration can replace a
discharge discussion.

The correct answer is B. Discharge instructions can be delegated to another health

professional provided they have the knowledge and skills to do so safely.
3. A 19 year-old student presents to the emergency department overnight with sudden onset of
abdominal pain. She is afebrile and her last menstrual period was 2 weeks ago. Her lab
investigations are unremarkable, including a negative serum BHCG. After a period of
observation, the diagnosis remains unclear, but her symptoms have improved. The physician
would like to keep the patient in the department until an abdominal/pelvic ultrasound can be
completed in the morning, but the student wishes to leave to write an exam. The physician
agrees to discharge her from the department.
Which of the following statements is MOST correct as it pertains to the physician’s decision to
discharge the patient?
a. He should tell the patient to return after her exam.
b. He should ask the patient to sign a “leaving against medical advice” form.
c. He should reassure the patient that the pain is likely due to mid-cycle ovulation and
advise her to use pain medication as required.
d. He should advise the patient that the diagnosis is uncertain and to return to the
emergency department if the pain worsens or if she develops a fever.

The correct answer is D. A discussion with the patient about important signs and
symptoms that would indicate a need to seek further medical attention is indicated. In
addition, efforts to explain why more observation, investigation, treatment and follow-up
care are recommended should be documented in the patient’s record.

4. While she provides instructions to her patients about the signs and symptoms to watch for
that may herald a complication or worsening of the condition, a busy physician who works in a
walk-in clinic always documents that aspect of her care as “Follow up PRN”.
Which of the following statements regarding documentation of the discharge discussion is
MOST correct?
a. Documentation of possible complications should be exhaustive.
b. Documentation of personalized discharge instructions will assist the physician in
defending an allegation of lack of informed discharge.
c. A standard brief notation such as “Follow up PRN” suffices to demonstrate the
physician’s diligence in providing discharge instructions.
d. Shorthand or abbreviations should not be used in documenting discharge
instructions.

The correct answer is B. Documentation of discharge instructions tailored to the patient,

even if brief, will provide evidence of the discussion that occurred on discharge.

5. A surgeon has developed a set of procedure-specific handouts for patients undergoing day
surgery. In an effort to standardize the approach to post-op care and monitoring, she would
like the handouts, which outline potential complications and which signs and symptoms to
watch for, to be provided by nursing staff at the time of discharge.
What additional step could the team include in the discharge process to enhance patient
safety?
 a. Include references for further reading for interested patients.
b. Provide patients with a telephone number and contact name in case they have
questions or concerns.
c. Encourage surgeons to review the handout with patients and make personalized
notes on it prior to discharge.
d. Save a copy of the handout in patients’ charts after discharge.

The correct answer is C. By reviewing the handout in person with the patient, the surgeon
is able to tailor the advice and gauge the patient’s understanding. Saving a copy of the
personalized handout in the patient’s medical record is an additional good practice.
 Competing priorities and team
situational awareness
Knowledge Check

1. In a labour and delivery unit, a team has adopted the phrase “Let’s chat” to signal that
whoever says this wants to have a quick word away from the patient to discuss concerns or
questions about what is happening. When someone says “Let’s chat,” both team members
step into the hall to discuss the concern.

This process is an example of:

a. Common or shared language
b. Escalating a concern
c. Debrief
d. Unscheduled huddle

The correct answer is A. The use of “Let’s chat” is an example of a team behaviour that
signals a need to re-examine everyone’s understanding of a given situation. It has been
established in this labour and delivery unit that when you hear those words, you step in the
hall to have a quick discussion.

2. An obstetrician is about to start a Caesarean section for a patient with arrested dilation at 6
cm with a normal fetal heart rate. As the obstetrician is moving the patient into the OR, the
midwife calls for a consultation because the patient she is caring for has arrested dilation at 8
cm.
Which of these statements would be the BEST next step for the obstetrician?

a. Ask the nurse to tell the midwife that they are unavailable since their patient needs a
Caesarean section.
b. Proceed with the Caesarean section and see the midwife’s patient once they have
finished.
c. Provide the midwife with an estimated timeline about how long the current Caesarean
section will take and ask if her patient can wait until the obstetrician has finished the
surgery.
d. Notify the nursing lead to call another team in case there is a need for two potential
Caesarean sections.

The correct answer is C. It is important for the obstetrician to communicate with the
midwife before proceeding with their surgery. By telling the midwife how long the surgery is
expected to take, the midwife can decide if their patient can wait or if they need more
urgent attention.
3. A patient presents to the unit where you are the OB on call. They are G1P0 at 33 weeks and
state they have a placenta previa and are now bleeding. The new ward clerk is unable to
locate any antenatal records for the patient. Which of the following will help improve team
situational awareness in this situation?
Choose the BEST response.

a. Call anaesthesia to let them know of the possibility of a Caesarean section.

b. Work with the nurse in charge to find a more experienced team member who may be
able to locate the antenatal records.
c. Ensure that everyone has a break before the surgery.
d. Raise your voice to ensure that everyone can hear you.

The correct answer is B. The new ward clerk in this scenario is unable to locate the
antenatal records and the team is working with incomplete information. This may have
occurred due to lack of training about how to search for or access this information.

4. True or False:
Calling out the elapsed time every 15 seconds once the head is out in a difficult shoulder
dystocia situation can help maintain individual and team situational awareness.

The correct answer is TRUE. Awareness of the passage of time can help to prevent task
fixation and alert the team that another approach may be needed.

5. True or False:
A post-procedure debrief provides an opportunity to celebrate “good catches” where effective
teamwork and communication prevented potential harm.

The correct answer is TRUE. Debriefs following a procedure or intervention are valuable
in celebrating “good catches” as a result of effective teamwork and communication.
Debriefs and identifying “good catches” are an important part of team learning that help to
promote team situational awareness and enhance safe care.
 Disclosing harm from healthcare delivery
Knowledge Check

1. A 65-year-old female develops an anaphylactic reaction after receiving IV contrast dye for a
CT scan. As part of her anaphylaxis treatment, the physician orders epinephrine
intramuscularly (IM). As the nurse is about to administer the epinephrine intravenously, he
double checks the route with the physician, who corrects him, and the epinephrine is
administered IM. The patient recovers uneventfully from her allergic reaction.
What term BEST describes this type of patient safety incident?
a. Close-call incident
b. Potential-for-harm incident
c. No-harm incident
d. Near miss

The correct answer is D. This event is identified as a near miss. The patient did not
receive the epinephrine intravenously, and therefore, did not suffer harm. Generally, a near
miss need not be disclosed to patients, unless there is a similar ongoing safety risk for that
patient.

2. A gastroenterologist performs a colonoscopy in a hospital outpatient endoscopy suite on a

patient with a history of rectal bleeding. The procedure is completed without complication. A
day later, the gastroenterologist is informed of a viral sterilization breach that affected the
endoscopy equipment used on the day of the patient's procedure. The patient reported no
symptoms of fever or illness when contacted by the gastroenterologist.
What term BEST describes this type of patient safety incident?
a. Harmful incident
b. Near miss
c. No-harm incident
d. Inherent risk of procedure incident

The correct answer is C. A no-harm incident results in an event that reaches the patient
and does not result in harm. Generally, they should be disclosed to patients, especially if
the potential for harm from the event exists in the future. In this scenario, the sterilization
breach poses a risk to the patient of subsequently developing a viral infection. As some
viral infections can evolve over time, the patient may need to be informed that serial
monitoring would be required.
3. A 48-year-old male undergoes a nephrectomy for renal cell carcinoma. Post-op, the surgeon
discovers that he removed the wrong kidney.
Which of the following is the BEST strategy for the surgeon in planning the initial disclosure
discussion with the patient?
a. At the initial disclosure discussion, the surgeon should explain that the wrong kidney
was removed because he believes the nurse prepped the patient improperly on the
wrong side.
b. The surgeon should base the initial discussion on the known facts, and not speculate
on possible reasons for the incident.
c. The surgeon should ensure that hospital legal counsel is present at the disclosure
discussion.
d. The surgeon should defer initiating the disclosure discussion until he has all the facts.

The correct answer is B. It would be important to provide information on the known facts
at the initial discussion, and not speculate or blame others involved in the patient’s care.
Reassuring the patient and/or SDM that more information will be provided when available
is also helpful to meet the patient’s needs.

4. A 38-year-old female undergoes an elective cholecystectomy. She is seen by her surgeon,

Dr. Small, for routine post-op care and complains of abdominal pain. Dr. Small assesses the
patient and finds no apparent cause for the patient's pain. The patient returns several weeks
later complaining of persistent abdominal pain that Dr. Small attributes to constipation. She
subsequently presents to the emergency department in acute abdominal distress and is
diagnosed with a retained surgical sponge in the right upper quadrant. She undergoes
laparotomy by a different surgeon, Dr. Williams, who removes the retained sponge.
Which of the following is MOST APPROPRIATE in terms of disclosing the the patient safety
incident in this scenario?
a. Following the laparotomy, Dr. Williams discloses to the patient that the retained
abdominal sponge was an error that should never have happened.
b. Dr. Williams discloses to the patient that Dr. Small left a sponge behind following the
cholecystectomy, which precipitated the exploratory laparotomy.
c. Following the laparotomy, Dr. Williams defers answering all of the patient's questions
about ongoing treatment to Dr. Small.
d. Following disclosure of the retained sponge to the patient, Dr. Williams documents
that Dr. Small was notified of the incident and that the incident was disclosed to the
patient.

The correct answer is D. Even though Dr. Williams did not perform the cholecystectomy
which gave origin to the retained sponge, he would be expected to disclose facts related to
the laparotomy, including the intra-operative finding of a retained surgical sponge.
Informing Dr. Small of the laparotomy findings and the disclosure may help Dr. Small
prepare for further discussions with the patient and questions about the incident. In this
instance, it would be prudent for Dr. Williams to document that Dr. Small was notified of the
incident and the disclosure steps taken to this point.
5. Apology legislation has been adopted in all Canadian provinces and territories, with the
exception of Yukon.
Which of the following statements is MOST correct regarding the objective(s) of apology
legislation?
a. To facilitate the determination of fault or liability following a harmful patient safety
incident.
b. To reduce concerns about the legal implications of making an apology following a
harmful patient safety incident.
c. To determine the aspects of disclosure which are permissible as evidence in a legal
proceeding.
d. To establish policies and standards regarding disclosure as set out by healthcare
facilities, institutions, and medical regulatory authorities.

The correct answer is B. One of the primary objectives of apology legislation is to

promote disclosure. It does so by reducing concerns about the legal implications of making
an apology following a harmful patient safety incident.
 Hospital policies – When
healthcare providers have
different opinions
Knowledge Check

1. You are the obstetrician on call when you overhear two midwives talking in the hallway. The
laboring patient they are caring for is refusing external fetal monitoring, despite concerns from
one of the midwives that they heard a deceleration after the last contraction using intermittent
auscultation.

What should be your next course of action?

a. You should escalate your concerns about the midwives not following the hospital
policy about fetal health surveillance to hospital leadership.
b. You should not interfere as you are not the MRP for this patient and you do not have
the right to be involved with their care without a consultation request from the
midwives.
c. Do nothing. You cannot do anything further since the patient has provided informed
refusal.
d. You should approach the midwives in the hallway and offer to assist them in
speaking with the patient if they wish.

The correct answer is D. Offering your support to the midwives in a collegial way can help
create a team atmosphere, demonstrate your support for the midwives, and provide the
patient with alternatives.

2. In the scenario above, which question should you ask yourself, as it pertains to informed
refusal?
Choose the BEST response.
a. Is the patient aware of the consequences of not having adequate fetal health
surveillance performed?
b. Is the patient aware that the risks of external monitoring are less than those
associated with internal scalp clip application?
c. Is the patient aware of the hospital policy about fetal health surveillance?
d. Is the patient’s decision to refuse monitoring reasonable?

The correct answer is A. Consequences of refusing care is an important part of the

informed refusal discussion.
3. In the scenario above, you speak to the midwives in the hallway but they do not want to
consult you as the patient has made their wishes clear.
Which of the following is the BEST next step?

a. Speaking directly with the patient as they may not understand the severity of the
situation.
b. Call the department head to resolve the situation.
c. Document your discussion in the patient’s chart.
d. Respectfully reiterate the purpose of the hospital policy and that the patient has no
choice.

The correct answer is C. Documenting your discussion is a reasonable next step to

ensure your offer of help is recorded. You may be constrained by factors such as whether
you know the patient’s name and whether you have access to the patient’s medical record.
Your hospital or institution may have policies or protocols for documentation in these
circumstances.

4. True or False:
The purpose of hospital policies is to accommodate practice variation and
regulatory compliance.

The correct answer is FALSE. The purpose of hospital policies is to REDUCE practice
variation and promote regulatory compliance. By reducing practice variation and
standardizing practice, we can promote the delivery of safe, high quality patient care.
 Interprofessional
communication in obstetrics
Knowledge Check

1. All of the following strategies help to support a “speaking up” culture EXCEPT?

a. Active listening.
b. Escalating concerns if necessary.
c. Adhering to the hierarchy of the team.
d. Reacting positively (i.e. thanking the person) even if the person speaking up is
wrong.

2. Which of the following is an important element to assist with speaking up?

a. Recognizing when someone is using CUS.
b. Hinting and hoping.
c. Not being too assertive.
d. Notifying the person you are speaking up to that you will escalate your concerns.

The correct answer is A. It is an important skill to recognize when someone is trying to

speak up to you. This is why standardizing the use of critical language such as CUS within
a team can help members recognize speaking up when it occurs.

3. You are the OB on call on a very busy night. When walking by the empty nursing station on
the way to the ER, you happen to notice on the central monitor that the FHR tracing is atypical
in room 2. This is not your patient, and the MRP is a midwife.
Choose the BEST course of action.
a. Wait until you return from the ER as it is not an abnormal tracing.
b. Go to the ER. The patient is being cared for by the midwife. Since you have not
heard that they are concerned, you can leave and return if they call you.
c. Quickly touch base with the midwife and alert them to the fact that you are going to
be away from the unit.
d. Ensure that you speak to the midwife about the atypical FHR tracing and the need
for a consultation now, before you leave the unit.
 The correct answer is C. This is the best course of action to improve team situational
awareness. By notifying the midwife that you may not be immediately available, they can
project ahead. If they feel that help is needed, they can ask for it sooner than they might
otherwise.

4. The nurse at triage calls the obstetrician on-call and says, “Ms. Martin is a G1P0 at 35
weeks who came in because she is bleeding and having regular contractions. She states she
only had one ultrasound at 18 weeks and was told she had a low placenta. What would you
like to do?”
The triage nurse’s summary is an example of?
a. 5-step advocacy.
b. Hinting and hoping.
c. Improving team situational awareness.
d. Assertive communication.

The correct answer is B. The nurse may assume that the obstetrician will understand that
the patient is in labour with a low placenta and may need an urgent Caesarean section.
However, they have not made their assessment clear to the obstetrician, and have not
assertively stated that the patient needs urgent attention.

5. As the obstetrician on call you are paged urgently into a labour and delivery room for a
severely hypertensive patient. You reach for IV labetolol, but in your rush you pick up
ergotamine. As you break the vial to draw it up, the midwife in the room taps you on the
shoulder and tells you that you have drawn up the incorrect medication.
The midwife’s reaction is an example of?
a. Hinting and hoping.
b. Cross-monitoring.
c. Escalating concerns.
d. Debriefing.

The correct answer is B. The midwife has noticed that the wrong drug was drawn up, and
is taking steps to correct it.
 Interprofessional conflict in
obstetrics
Knowledge Check

1. You are the obstetrician on call when a nurse calls you to assess a post-partum patient for
pain management. You see the patient and write an order for hydromorphone 5 mg po. When
they see your order, the nurse calls you and says “[Link], I’m concerned….” Which of the
following best describes the nurse’s actions?

Choose the BEST response.

a. Ensuring clear roles and responsibilities.

b. Promoting psychological safety.
c. Employing critical language.
d. Creating a shared mental model.

The correct answer is C. The statement “I’m concerned” is the “C” in CUS, which is a
critical language tool for speaking up.

2. True or False:
Lack of understanding about the scope of practice of other HCPs is a contributing factor to
failure of collaborative care.

The correct answer is TRUE. Lack of understanding about the scope of practice of other
HCPs may contribute to misunderstanding about who is responsible for certain aspects of
patient care. Incomplete understanding may also contribute to erroneous assumptions
about what other HCPs are able to do. Misunderstandings and assumptions may lead to
conflict and undermine collaborative care.

3. True or False:
Poor team communication can be linked to patient safety incidents.

The correct answer is TRUE. Poor team communication can result in poor team
situational awareness, which may lead to patient safety incidents. When some members of
the team are missing information, they are unable to anticipate problems and project ahead
to foster patient safety.
4. True or False:
One of the benefits of collaborative care is that it provides patients with HCPs that have similar
skills and knowledge to assist with their healthcare decisions.

The correct answer is FALSE. One of the benefits of collaborative care is that it provides
patients with HCPs who have DIFFERENT skills and knowledge to assist with their
healthcare decisions.
 Medical letters, forms and reports
Knowledge Check

1. A 38-year-old office employee calls your office and speaks with your receptionist, requesting
a medical letter indicating that he has been unwell and unable to work for the past week. You
did not see the patient when he was ill, nor did he seek an alternative medical assessment.

What would be your next BEST step?

a. Provide the letter because you trust this patient.
b. Refuse to write the letter, because you cannot verify the patient was ill.
c. Write the letter indicating “the patient states he has been off work for one week due
to medical illness.”
d. Ask the patient to make an appointment so that you can clinically assess him, and
decide on how to proceed.

The correct answer is D. In general, a medical letter must be written based on a

physician’s assessment, be that virtual or in person, and supported by your documentation
in the medical record. It would be prudent to at least speak with the patient to assess his
medical condition, and ensure he requires no further medical intervention. Document your
assessment in the record, as well as whether a medical letter was provided, and the
duration of time off work. Alternatively, if the medical information can’t be verified, you may
consider writing “patient states…” in your medical letter.

2. You are the family physician for a 48-year-old businesswoman with systemic lupus
erythematosus. She is applying for long-term disability benefits from her insurance company.
You have received written authorization from her to complete a medical form and to release
her entire medical record to the insurance company. The patient has a history of major
depression related to past trauma, which does not impact her ability to work. You are not sure
how the patient would feel about that information being released.
What would be the next BEST step?
a. Contact the insurance company and offer to dictate a summary note.
b. Call the insurance company to inform them you have concerns about some aspects
of the medical record.
c. Call your patient to clarify any restrictions on what she consents to be released.
d. Carefully complete the form, indicating "I don't know" for those questions dealing
with mental health.

The correct answer is C. In general, although the patient has already provided written
authorization to her insurance company, it would be prudent to confirm patient consent
before preparing or releasing their information. This provides an opportunity to clarify with
the patient regarding your response to some of the questions, as well as any restrictions
regarding specific information the patient consents to sharing. Physicians have a
professional obligation to prepare medical forms accurately to the best of their knowledge.
3. A lawyer sends a request to your office for a report regarding your medical care to a patient
over the past ten years. In addition, the lawyer includes a signed consent from the patient
authorizing you to release the patient’s complete medical record to them. The lawyer is
requesting the report within 30 days, as the patient is going to trial in two months. You are just
about to start parental leave from your practice for a few months.
What would be the next BEST step?
a. Send a copy of the medical record and hope it will suffice, as it’s the best you can do
before your parental leave begins.
b. Ask a colleague to help you complete the medical report and let the lawyer know.
c. Call the lawyer to acknowledge the request and advise them regarding a potential
delay.
d. Request extra payment to compensate for your time and inconvenience, as you will
likely need to prepare the report during your parental leave.

The correct answer is C. It would be best to acknowledge the request and advise the
lawyer regarding the potential delay, to clarify when you are able to respond to the request.
Delays or failure to complete a medical report may be considered as a potential breach of a
physician’s professional obligations to a patient.

4. A 35-year-old separated mother of three young boys requests a letter from you, stating her
sons should not travel with her ex-husband and his girlfriend because the boys are having
nightmares about the trip and are greatly distressed.
What would be the BEST next step?
a. Refuse to write the letter because you don't want to be in the middle of this family
conflict.
b. Tell the mother you can only write an objective letter stating the facts as known to you.
c. Suggest the mother obtain a letter from her lawyer, as it would carry more weight.
d. Accept to write the letter because you are concerned that the ex-husband will abduct
the children.

The correct answer is B. It would be prudent to communicate with the mother regarding
your professional obligations to be objective and factual. You could suggest to the mother
to bring the boys to the clinic for an assessment, so that you can explore the concerns. Any
letter provided should be based on your medical knowledge and assessment documented
in the boys’ medical records.
5. A previously healthy 52-year-old office manager undergoes surgery for uncomplicated
appendicitis. At his three-week follow-up with the surgeon, he requests a medical form to be
completed for his work absence. The patient states that he needs longer than the
recommended recovery period, and feels that he will be too unwell to return to work. Based on
her assessment, the surgeon expects that the patient would be well enough to resume all
normal activities.
What would be the next BEST step?
a. Ask the patient to complete the medical form, and you will sign off on it.
b. Advise the patient to follow-up with his family physician for any further assessments
and completion of the medical form.
c. Refuse the patient’s request, as in her medical opinion he does not require more
time off work.
d. Fill out the form for the usual recommended leave from work, but advise the patient
to contact her if he still feels unable to work at the end of that time period.

The correct answer is D. It would be prudent for the surgeon to communicate with the
patient regarding her professional obligation to be objective and factual. Exploring the
patient’s concerns would be helpful as part of the assessment, to ensure she understands
the particulars of the patient’s work that may be affected by his post-op condition.
 Negligence and civil liability
Canada
Knowledge Check

1. What are the key elements that need to be established, on a balance of probabilities, for a
claim of negligence to be successful in a civil legal action.

Select the MOST correct statement?

a. Standard of care, error in judgment, harm, causation.
b. Breach of standard of care, causation, damages.
c. Duty of care, harm or injury, liability, error in judgment.
d. Duty of care, breach of duty of care, harm, causation.

The correct answer is D. In order for a claim of negligence to be successful in a civil legal
action, a plaintiff must prove, on the balance of probabilities, the existence of a duty of care
by the defendant, that the defendant breached this duty, that harm occurred, and that the
breach of duty caused the harm (causation).

2. A 48 year-old male suffers renal failure and end-stage kidney disease. He is a known
diabetic, and had been receiving regular care from his endocrinologist. He initiates a civil legal
action against his endocrinologist, alleging the kidney damage was preventable.
Which statement BEST describes what the courts would consider in determining whether or
not the standard of care was met in this patient’s care?

a. If the standard of care is followed, poor outcomes should not occur.

b. The standard of care is perfection in medical care.
c. The standard of care is the level of care and skill reasonably expected of a physician
with similar circumstances.
d. The standard of care is based on existing published guidelines for care of patients
with diabetes.

The correct answer is C. The standard of care is determined by the level of care and skill
reasonably expected of a physician with similar training, working in similar circumstances.
To determine whether reasonable care was provided, courts consider a number of different
sources, including medical expert opinion, published and accepted clinical guidelines, and
policies and recommendations of the Colleges at the time the care was provided.
3. A 40 year-old female is diagnosed with cervical cancer and requires a hysterectomy. She
later discovers that her family physician had received an abnormal result from her last pap test,
which was filed without action. She initiates a civil legal action against her family physician
alleging that the delay in diagnosis and treatment of her cervical cancer has resulted in her
being infertile.

Which statement BEST describes the concept of causation?

a. The plaintiff (patient) must establish that the family physician had a duty of care that
triggered an obligation to follow the standard of care.
b. The plaintiff (patient) must establish that the family physician breached the standard
of care and demonstrate a causal connection between the alleged breach and the
harm.
c. The plaintiff (patient) must establish that the family physician breached their duty of
care by not following the standard of care.
d. The plaintiff (patient) must establish that the family physician had a duty of care to
the patient and that they breached their duty of care.

The correct answer is B. To establish causation in a civil legal action alleging negligence,
the plaintiff must establish, on the balance of probabilities, that there is a relationship, or
causal connection, between an alleged breach of the standard of care and the stated harm
or injury.

4. A 24 year-old female presents to the emergency department with a two-day history of

headache. After a thorough assessment, the patient is discharged with follow-up instructions
including symptoms to watch for. Twelve hours later, the patient returns to the emergency
department with a worsening headache and new fever, and is diagnosed with meningitis. A civil
legal action is initiated by the patient alleging that the delay in diagnosis was the result of
negligent care by the emergency physician. The legal counsel for the plaintiff and defendant,
respectively, seek opinions of other emergency physicians as medical experts in the matter.
Which statement regarding medical experts is MOST correct?
a. Experts testifying in court must be physicians.
b. The medical expert’s duty is to advocate for the party who retains them.
c. Medical experts assist the court in determining issues outside the court’s direct
knowledge, such as what would constitute a reasonable standard of knowledge and
skill in a particular circumstance.
d. Only emergency physicians with highly specialized training are suitable as medical
experts in a medico-legal matter involving emergency care.

The correct answer is C. In order to assist the court in determining what constitutes a
reasonable standard of knowledge and skill in a particular circumstance, medical experts
have a duty to be objective and impartial. Experts on standard of care are generally of
similar training and experience as the defendant physician. They may use clinical practice
guidelines to support their interpretation of the standard of care.
5. A 19 year-old male suffers from cerebral palsy, which he believes is due to prolonged
maternal labour and delivery. He launches a civil legal action alleging civil liability against the
family physician who delivered him 19 years ago.
Which statement BEST describes how the court would determine the standard of care
expected from the family physician?
a. The level of care and skill reasonably expected of an obstetrician at the time the
care was provided (19 years ago).
b. The level of care and skill reasonably expected of an obstetrician at the time of the
trial.
c. The level of care and skill reasonably expected of a family physician providing
intrapartum obstetric care at the time the care was provided (19 years ago).
d. The level of care and skill reasonably expected of a family physician providing
intrapartum obstetric care at the time of trial.

The correct answer is C. Since the defendant in this matter is a family physician providing
intrapartum obstetric care, the courts would consider the standard of care as the level of
care and skill a reasonable, normal, prudent family physician providing intrapartum
obstetric care, would have provided at the time of the delivery (19 years earlier).
 Negligence and civil liability
Québec
Knowledge Check

1. What are the elements that need to be established, on a balance of probabilities, for a claim
of civil liability to be successful in a civil legal action

Select the MOST correct statement?

a. Duty of care, injury, causation.
b. Injury, liability, compensation.
c. Error in judgment, injury, causation.
d. Fault, injury, causation.

The correct answer is D. In order to be successful in a civil legal action in Québec, a

plaintiff must prove that the defendant committed a fault, that the plaintiff suffered injury,
and that the fault caused the harm or injury suffered by the plaintiff (causation).

2. A 48 year-old male suffers renal failure and end-stage kidney disease. He is a known
diabetic, and had been receiving regular care from his endocrinologist. He initiates a civil legal
action against his specialist, alleging the kidney damage was preventable.
Which statement BEST describes what the courts would consider in determining whether or
not the standard of care was met in this patient’s care?

a. Poor outcomes are generally considered to be the result of a fault.

b. The court expects perfection in medical care.
c. The standard of care is the level of care and skill reasonably expected of a physician
with similar training and working in similar circumstances.
d. The standard of care is the level of care and skill reasonably expected of a physician
with similar training and working in similar circumstances.

The correct answer is C. Courts determine the standard of care based on whether the
clinical care provided to the patient reflected the care that would have reasonably been
provided by a physician with similar training and experience. The threshold of reasonable
care is determined with the assistance of a number of different sources, including medical
expert opinion, published and accepted clinical guidelines, and policies and
recommendations of the Colleges at the time the care was provided.
3. A 40 year-old female is diagnosed with cervical cancer and requires a hysterectomy. She
later discovers that her family physician had received an abnormal result from her last pap test,
which was filed without action. She initiates a civil legal action against her family physician
alleging that the delay in diagnosis and treatment of her cervical cancer has resulted in her
being infertile.
Which statement BEST describes the concept of causation when proving civil liability?
a. The plaintiff (patient) must establish that the family physician had a duty of care that
triggered an obligation to follow the standard of [Link] plaintiff (patient) must
establish that the family physician breached their duty of care by not following the
standard of care.
b. The plaintiff (patient) must establish that the family physician breached the standard
of care and demonstrate a causal connection between the alleged breach and the
harm.
c. The plaintiff (patient) must establish that the family physician breached their duty of
care by not following the standard of care.
d. The plaintiff (patient) must establish that the family physician had a duty of care to
the patient and that they breached their duty of care.

The correct answer is B. To establish causation, the plaintiff must establish, on the
balance of probabilities, that there is a relationship, or causal connection, between an
alleged breach of the standard of care and the stated harm or injury.

4. A 24 year-old female presents to the emergency department with a two-day history of

headache. After a thorough assessment, the patient is discharged with follow-up instructions
including symptoms to watch for. Twelve hours later, the patient returns to the emergency
department with a worsening headache and new fever, and is diagnosed with meningitis. A civil
legal action is initiated by the patient alleging that the delay in diagnosis was the result of
negligent care by the emergency physician. The legal counsel for the plaintiff and defendant,
respectively, seek opinions of other emergency physicians as medical experts in the matter.
Which statement regarding medical experts is MOST correct?
a. Experts testifying in court must be physicians.
b. The medical expert’s duty is to advocate for the party who retains them.
c. Medical experts assist the court in determining issues outside the court’s direct
knowledge, such as what would constitute a reasonable standard of knowledge and
skill in a particular circumstance.
d. Only emergency physicians with highly specialized training are suitable as medical
experts in a medico-legal matter involving emergency care.

The correct answer is C. In order to assist the court in determining what constitutes a
reasonable standard of knowledge and skill in a particular circumstance, medical experts
have a duty to be objective and impartial. Experts on standard of care are generally of
similar training and experience as the defendant physician. They may use clinical practice
guidelines to support their interpretation of the standard of care.
5. A 19 year-old male suffers from cerebral palsy which he believes is due to prolonged
maternal labour and delivery. He launches a civil legal action alleging civil liability against the
family physician who delivered him 19 years ago.
Which statement BEST describes how the court would determine the standard of care
expected from the family physician?

a. The level of care and skill reasonably expected of an obstetrician at the time the
care was provided (19 years ago).
b. The level of care and skill reasonably expected of an obstetrician at the time of the
trial.
c. The level of care and skill reasonably expected of a family physician providing
intrapartum obstetric care at the time the care was provided (19 years ago).
d. The level of care and skill reasonably expected of a family physician providing
intrapartum obstetric care at the time of trial.

The correct answer is C. Since the defendant in this matter is a family physician providing
intrapartum obstetric care, the courts would consider the standard of care as the level of
care and skill a reasonable, normal, prudent family physician providing intrapartum
obstetric care, would have provided at the time of the delivery (19 years earlier).
 Privacy and confidentiality
Knowledge Check

1. A 72-year-old male presents to an emergency department for assessment of new-onset

chest pain. The patient is unsure of his current medication list, and the emergency physician is
unable to reach the family physician. The emergency physician contacts the patient’s
pharmacist to request a current medication list.

In this situation, which of the following statements BEST describes the appropriate patient
consent needed to disclose personal health information (PHI) to other healthcare providers?
a. Express verbal consent from the patient is required by the pharmacist to release the
patient’s PHI.
b. Written authorization from the patient faxed to the pharmacist is required for the
pharmacist to release the patient’s PHI.
c. The emergency physician is part of the circle of care, and therefore the pharmacist
can assume the patient has consented to share their PHI.
d. The request for the medication list needs to come from the patient’s family physician.

The correct answer is C. Sharing personal health information within the circle of care is
essential for both quality of care and safety. In general, patient consent is implied within the
patient’s circle of care, where it is assumed that the patient seeking care provides
permission to the treating physician to collect and use personal information to assist in
addressing ongoing care issues.

2. A 22-year-old female is assessed in a medical clinic for a particularly sensitive issue. Before
she reveals her situation, she asks whether everything discussed and documented at the
appointment will be confidential and never shared.
What would be the next BEST step for the physician?
a. The physician should reassure the patient that as part of a physician’s fiduciary duty
to their patients, she can be ensured of complete confidentiality.
b. The physician should advise the patient that her assessment will be documented in
the medical record, but that her personal health information (PHI) cannot be
released to a third party without her authorization.
c. The physician should advise the patient that physicians are obligated to document
information the patient discloses as part of their medical assessment, but that she
can request that specific information not be documented in the medical record.
d. The physician should advise the patient that physicians have a legal and
professional obligation to protect their patients’ PHI, but that there may be specific
situations where PHI may be disclosed without consent, as required or permitted by
law.
 The correct answer is D. Personal health information may be disclosed without consent,
as permitted or required by law (such as concerns related to fitness to drive, child
protection and infection control).

3. A 46-year-old male, who is the sole provider for his family, applies for increased coverage
from his life insurance company. The company sends the medical assessment form to the
patient’s family physician, which includes a signed authorization by the patient for the release
of his medical records to his insurance broker. In reviewing the patient’s medical record, his
physician notes that the patient was treated for substance abuse by a different physician 15
years ago.
What is the physician’s next BEST step?
a. Speak with the patient to clarify what parts of the medical record can be disclosed to
the insurance company, as well as document the discussion and the consent, in the
record.
b. Submit a copy of the entire medical record as this is what the patient’s signed
authorization has specified.
c. Submit a copy of the entire medical record with the section on substance abuse
redacted. Indicate on a separate page that a portion of the medical record has been
redacted.
d. Speak with the medical officer at the insurance company to see whether the
insurance company requires medical records beyond the past 10 years.

The correct answer is A. If there is potentially sensitive information in a patient’s medical

record, it would be prudent to clarify any specific requests that the patient may have
regarding limits on the personal health information (PHI) provided to a third party, and
document the discussion and consent in the record. It may be important to discuss the fact
that note of any redaction would need to be made in the response.

4. A 62-year-old widow with advanced metastatic colon cancer is admitted to your hospital
team. She has requested medical assistance in dying (MAiD) and has been assessed and
deemed capable to make her own medical decisions. She has no children, and is estranged
from her only sibling (a brother whom she has not spoken to in over eight years). Her
distraught brother calls to speak with you, requesting an update on his sister’s medical
condition.
As her attending physician, what is your next BEST step?
a. As the patient is imminently dying, advise the brother, who would be her substitute
decision-maker, that he should come see her soon.
b. Speak with the patient first regarding her brother’s request and obtain her consent to
share information about her condition.
c. Advise the patient that it would be best to make amends with her brother and obtain
her consent to share information with her brother.
d. Have the social worker speak to her brother regarding her medical condition.
 The correct answer is B. It is important to speak to the patient first to obtain their consent,
as physicians have a professional obligation to protect the privacy and confidentiality of a
patient’s PHI.

5. A 17-year-old female requests oral contraceptives from her family physician. The physician
counsels her appropriately and initiates treatment. Her father is also a patient, and at his next
appointment asks if his daughter is sexually active.
What is the BEST next step for the family physician?
a. Advise the father that he doesn’t know.
b. Advise the father that he has a legal and professional obligation to maintain
confidentiality, and that he is not able to discuss his daughter’s (PHI) without her
consent.
c. Inform the daughter of her father’s inquiry, and ask for her consent to discuss with
her father.
d. Advise the father that he would only be able to release his daughter’s PHI if she was
a minor.

The correct answer is B. Physicians have a legal and professional obligation to protect
the privacy and confidentiality of a patient’s PHI, and require express consent by the
patient to share this information.
 Professional autonomy, scope of
practice, and collaborative care
Knowledge Check

1. An obstetrician is on call with a third year resident in OB/GYN. The resident calls the
obstetrician to let them know that they have been watching a fetal heart rate (FHR) tracing that
is abnormal and that they believe a Caesarean section is now indicated. When the obstetrician
arrives, they note that the tracing has been abnormal for some time, and feels that they would
have delivered this patient much sooner had they been aware of the situation.

If an adverse outcome ensues, and a court finds the resident's care was negligent, what kind
of liability might the obstetrician be exposed to as the resident's supervisor?

a. Direct liability
b. Vicarious liability
c. Vicarious and direct liability

The correct answer is A. Direct liability may be incurred if there is a failure of supervision
of the resident. It is up to the court to determine whether the supervision met the standard
of care.

2. In the same situation, what liability might the resident incur if a court found their care to be
negligent?
a. Direct liability
b. Vicarious liability
c. No liability
d. Vicarious and direct liability

The correct answer is A. Direct liability may be incurred if the court determines that the
resident did not meet the standard of care expected of a resident with a similar level of
training.
3. A G2P1 patient of family medicine obstetrics is admitted in labour at 39 weeks. The family
doctor on call assesses the patient and encourages ambulation. A cord prolapse occurs and
the nurses activate an emergency protocol. There is a delay in getting an urgent caesarian
section due to unavailability of anaesthesia.
Which of the following statements is true?

a. The obstetrician on call is ultimately responsible for the outcome through vicarious
liability.
b. The anesthetist can only be called by the obstetrician as this falls outside the scope
of practice of family physicians.
c. The family physician did not have professional autonomy in this situation.
d. The nurses have professional autonomy to activate an emergency protocol for a
team response to this obstetrical emergency.

The correct answer is D. Professional autonomy means that regulated independent HCPs
are responsible and individually accountable for their clinical decisions and actions.
Activating an emergency response to this crisis falls within the scope of practice of the OB
nursing staff.

4. Which of the following statements is consistent with promoting patient safety when working
in a multidisciplinary environment?
Choose the BEST response.
a. Informing a capable patient’s family when transfer of care is required.
b. Establishing morning huddles where providers clarify their responsibilities for each
patient.
c. Assuming the roles of the MRP after a consult with the midwife’s patient.
d. Supervising all of the work of the nurses involved with a high risk obstetrical patient.

The correct answer is B. Clarifying roles and responsibilities is an important way to

improve patient safety. It is also important to clarify the identity of the MRP.
 Speaking Up
Knowledge Check

1. Which of the following are important elements to assist with speaking up?
Choose the BEST response.
a. Hinting and hoping.
b. Not being too assertive.
c. Notifying the person you are speaking up to that you will escalate your concerns.
d. Recognizing when someone is using CUS.

The correct answer is D. It is an important skill to recognize when someone is trying to

speak up to you. This is where critical language such as CUS can be helpful to alert the
receiver about what is happening.

2. You are the staff emergency physician on duty when EMS patches about an incoming
trauma patient. You are working with two postgraduate trainees and nurses that you have not
worked with before. You want to prepare your team for the incoming trauma and optimize
teamwork.
In this situation, which of the following statements BEST supports patient safety?
a. Ask the junior residents to stay out of the way in this case.
b. Hold a huddle before the patient arrives to discuss individual roles and encourage
team members to speak up if they see something they question.
c. Remind your team about the hospital policies related to X-rays in the emergency
department.
d. Tell people to be on their toes and ask everyone to take their breaks now, since this
case may require prolonged attention.

The correct answer is B. Huddles help to foster team situational awareness and break
down communication barriers.
3. You are a staff surgeon in the middle of a hysterectomy. Your assistant is a first-year
surgery resident. You are about to divide the ovarian blood supply when the resident speaks
up, as they are worried about the location of the ureter.
Which of the following statements BEST reflects use of a standardized communication tool
demonstrating effective speaking up by the resident?
a. “Do you know who is on call today for urology?”
b. “Have you ever had a complication doing this surgery?”
c. “I am concerned about the location of the ureter.”
d. Remaining quiet since the surgeon has to concentrate at this difficult step in the
operation.

The correct answer is C. This is the “C” for “concerned” in the CUS approach to graded
assertiveness.

4. Which of the following actions does NOT support a speaking up culture?

a. Active listening.
b. Escalating concerns if necessary.
c. Adhering to the hierarchy of the team.
d. Reacting positively (i.e. thanking) even if the person speaking up is wrong.

The correct answer is C. Adhering to hierarchy is NOT a component of a speaking up

culture. Strict hierarchy limits psychological safety within the team.

5. As the obstetrician on call you are called urgently into a labour and delivery room for a severely
hypertensive patient. You reach for IV labetolol, but in your rush you pick up ergotamine. As you
break the vial to draw it up, the midwife in the room taps you on the shoulder and indicates that
you may have drawn up the incorrect medication.
Which of the following communication behaviours BEST exemplifies the midwife’s reaction?

a. Hinting and hoping

b. Cross-monitoring
c. Escalating concerns
d. Briefing

The correct answer is B. The midwife has noticed that the wrong drug was drawn up and
is taking steps to correct it.