A 76-year-old man is brought to the emergency department from a nursing home in critical condition due to fever and confusion. His nursing home records were not transferred with him. On initial evaluation, his temperature is 38.9 C (102 F), blood pressure is 75/50 mm Hg, and heart rate is 120/min. The patient is obtunded and cannot provide a history. He is immediately intubated and placed on mechanical ventilation. An internal jugular venous central line is placed and infusion of normal saline boluses is initiated. The covering clinician places a STAT order for cefepime and contacts the on-call pharmacist to expedite order approval. The antibiotic is administered as soon as it arrives in the emergency department. Shortly thereafter, the patient develops profound hypotension, skin rash, and respiratory distress. Despite resuscitation efforts, he expires. Retrospective review of the nursing home paperwork shows documentation of severe penicillin and cephalosporin allergy. Which of the following interventions would improve patient safety during similar high-risk situations?

Question

A 76-year-old man is brought to the emergency department from a nursing home in critical condition due to fever and confusion.  His nursing home records were not transferred with him.  On initial evaluation, his temperature is 38.9 C (102 F), blood pressure is 75/50 mm Hg, and heart rate is 120/min.  The patient is obtunded and cannot provide a history.  He is immediately intubated and placed on mechanical ventilation.  An internal jugular venous central line is placed and infusion of normal saline boluses is initiated.  The covering clinician places a STAT order for cefepime and contacts the on-call pharmacist to expedite order approval.  The antibiotic is administered as soon as it arrives in the emergency department.  Shortly thereafter, the patient develops profound hypotension, skin rash, and respiratory distress.  Despite resuscitation efforts, he expires.  Retrospective review of the nursing home paperwork shows documentation of severe penicillin and cephalosporin allergy.  Which of the following interventions would improve patient safety during similar high-risk situations?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfe1_5a0d_8f63_97743132b21b_MD0005_00 In this scenario, the patient was given a medication to which he was allergic, resulting in a fatal anaphylactic reaction. In health care, as in other settings, errors can happen when multiple systems fail in succession. The Swiss cheese model (Figure) shows that a process has many layers of defense, but all these layers have holes. When all of the holes line up, an error can occur. In this case, the patient's nursing home records were not available, and there was no opportunity for verbal or written handoff communication of potential allergies. Given the patient's critical clinical condition, broad-spectrum antibiotics were ordered without checking for allergies. In an attempt to expedite care, these antibiotics were dispensed and administered on an emergency basis. Multiple efforts to improve patient safety have been developed to decrease the "size" of the holes in the layers of defense. One such method is to increase redundancy and double checks, especially for high-risk processes. For example, allergies can be verified multiple times by multiple providers, flagged by the electronic medical record (EMR) system, and documented in multiple locations in the medical record and on patient wristbands. (Choice B) Automating key functions can help prevent errors from occurring due to variations in patients and processes. For example, EMR systems are often set to automatically prompt clinicians to verify allergies before ordering medications on newly admitted patients or to signal possible drug-drug interactions between medication orders. (Choice C) With increasing shift work in health care, patient handoffs have become both increasingly prevalent and a source of medical errors. Standardized handoffs that use checklists and mnemonics have resulted in improved safety and decreased medical errors. These tools take the burden off clinicians to conduct handoffs purely by memory. (Choice D) Systems should be improved both retroactively and proactively. A retroactive system responding to errors that have already occurred will be less effective at finding and preventing new ones. (Choice E) Safety generally improves when multiple members of a care team participate in communication and decision making. For instance, procedural timeouts often require the involvement of surgeons, anesthesiologists, nurses, and technicians to all verify the details of a procedure. Educational objective: In the Swiss cheese model, a process has many layers of defense but all layers have holes. When the holes line up, an error can occur. Many different methods, including redundancy and double checks during high-risk processes, have been developed to reduce these holes and the likelihood of error. References: Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. (http://www.ncbi.nlm.nih.gov/pubmed/24302089)

A 76-Year-Old Man Is Brought to the Emergency Department from a Nursing