A 53-year-old man with end-stage renal disease is admitted to the hospital for complications related to his arteriovenous fistula. Medical history includes type 1 diabetes, diabetic nephropathy, diabetic neuropathy, and diabetic ophthalmopathy. During the daytime nurse's assessments, the patient is consistently hypertensive with systolic blood pressure of 160-170 mm Hg, both pre- and post-dialysis, despite adherence to his antihypertensive regimen. The nurse phones the physician, who orders that the patient be started that evening on hydralazine 25 mg 3 times a day. However, the nurse instead enters an order for hydroxyzine 25 mg 3 times a day. The order for hydroxyzine is processed and approved by the pharmacy. After retrieving the patient's medications, the evening-shift nurse is surprised the patient is taking hydroxyzine as he has not reported any itching. Before administering hydroxyzine, the nurse pages the physician who wrote the order and asks for clarification. The physician recognizes what has happened and corrects the order.
Which of the following is the most appropriate course of action in response to the error?

Question

A 53-year-old man with end-stage renal disease is admitted to the hospital for complications related to his arteriovenous fistula.  Medical history includes type 1 diabetes, diabetic nephropathy, diabetic neuropathy, and diabetic ophthalmopathy.  During the daytime nurse's assessments, the patient is consistently hypertensive with systolic blood pressure of 160-170 mm Hg, both pre- and post-dialysis, despite adherence to his antihypertensive regimen.  The nurse phones the physician, who orders that the patient be started that evening on hydralazine 25 mg 3 times a day.  However, the nurse instead enters an order for hydroxyzine 25 mg 3 times a day.  The order for hydroxyzine is processed and approved by the pharmacy.  After retrieving the patient's medications, the evening-shift nurse is surprised the patient is taking hydroxyzine as he has not reported any itching.  Before administering hydroxyzine, the nurse pages the physician who wrote the order and asks for clarification.  The physician recognizes what has happened and corrects the order.
Which of the following is the most appropriate course of action in response to the error?

Quizplus · Accepted Answer

In this scenario, a medication error is identified and corrected before the patient received the wrong medication and so the patient is unharmed. Such incidents are characterized as "near-miss" events, as a negative outcome could have occurred but did not, either by chance or, as in this case, due to timely intervention. Near misses are much more common than adverse events but their root causes are similar. Therefore, identifying root causes of near misses can help prevent future adverse events. This event should be reported to the hospital administration (eg, using a medical event-reporting system) to identify weaknesses in the system of care that jeopardize patient safety (eg, lack of a standardized process for verbal orders) and to help develop formal corrective measures. When an error is corrected before a patient is harmed, the physician should use professional judgment when considering whether to inform the patient. Disclosing the near miss may be distressing to some patients or confuse them unnecessarily. However, if the patient is aware of the near miss, disclosure is recommended as it will decrease anxiety and improve trust and confidence. In contrast, any medical error that impacts patient care or causes harm to a patient should be promptly disclosed. (Choices A and C) Disclosure to the patient is not mandatory as there was no impact on the patient's care. However, if the patient is aware of the medication error, then disclosure would be advisable to preserve the physician-patient relationship. (Choice B) Although there was no harm to the patient, the incident should be reported to hospital administration for analysis to help prevent similar medication errors that could lead to adverse events. (Choice E) It is not necessary to report to the Joint Commission a near miss that was corrected before reaching the patient. Educational objective: Near-miss events should be reported to the hospital administration as analysis can assist in the identification and correction of errors that jeopardize patient safety. __________ References: Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. (http://www.ncbi.nlm.nih.gov/pubmed/26126125) Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes. (http://www.ncbi.nlm.nih.gov/pubmed/26152435)

A 53-Year-Old Man with End-Stage Renal Disease Is Admitted to the Hospital