A 74-year-old man is brought to the emergency department after being found unconscious at home. Emergency medical personnel report that he was in complete heart block when they arrived. The patient's history is significant for a myocardial infarction 12 years ago, with subsequent congestive heart failure. He has been admitted to the hospital twice over the past 3 months, once for decompensated heart failure and once for atrial fibrillation with rapid ventricular response. In reviewing the home medications brought in by his wife, the physician notes that the patient is taking aspirin; dabigatran; furosemide; apixaban; lisinopril; extended-release metoprolol; and atenolol. The wife reports that he takes these medications regularly and they were all prescribed by his doctors. He sees a primary care physician and a cardiologist, who work within the same hospital system. The patient's son, a pharmacist, expresses disappointment after learning of his father's complete heart block and prescription for 2 different beta blockers and oral anticoagulants. Which of the following actions would be most helpful in preventing the medical error that led to this patient's outcome from occurring again in the future?

Question

A 74-year-old man is brought to the emergency department after being found unconscious at home.  Emergency medical personnel report that he was in complete heart block when they arrived.  The patient's history is significant for a myocardial infarction 12 years ago, with subsequent congestive heart failure.  He has been admitted to the hospital twice over the past 3 months, once for decompensated heart failure and once for atrial fibrillation with rapid ventricular response.  In reviewing the home medications brought in by his wife, the physician notes that the patient is taking aspirin; dabigatran; furosemide; apixaban; lisinopril; extended-release metoprolol; and atenolol.  The wife reports that he takes these medications regularly and they were all prescribed by his doctors.  He sees a primary care physician and a cardiologist, who work within the same hospital system.  The patient's son, a pharmacist, expresses disappointment  after learning of his father's complete heart block and prescription for 2 different beta blockers and oral anticoagulants.  Which of the following actions would be most helpful in preventing the medical error that led to this patient's outcome from occurring again in the future?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0d7_044b_8f63_cb753de65135_MD0005_00 Preventable medical errors present considerable risk to patient safety. Within large systems of care, checks and balances exist to prevent or minimize medical errors and resulting adverse events. This system of safety checks may fail, requiring an examination of what occurred and how it could have been prevented. A root cause analysis is a quality improvement tool used to identify what, how, and why an undesirable outcome occurred. When investigators determine why an event or failure occurred, they can recommend corrective measures to prevent future occurrences. Root cause analysis requires 5 steps (Table). The first involves collecting data about the event. Data collection often includes interviewing multiple individuals involved to understand how and why the adverse outcome occurred. Review of the medical record and speaking with the patient's pharmacist, cardiologist, and wife would assist in understanding the causal factors leading to the adverse outcome, but analyzing each component individually may not be sufficient in understanding the underlying causes of the error. Root cause analysis would include these components in addition to systematic analysis of contributing factors (Choices A, B, C, and D). The second step involves creating a flow chart with causal factors, or contributors that, if eliminated, could have prevented the outcome or reduced its severity (ie, human error). The third step involves identifying the reasons behind each causal factor, termed the root cause. This step assists investigators in understanding why particular causal factors exist or occurred. For example, the primary care physician may not have realized that the patient was already on a beta blocker/anticoagulant (causal factor), due to inadequate training on how to use a new electronic health record system, due to lack of funding for adequate training (root cause). The fourth step involves generating recommendations and implementing them. The fifth step requires assessing the success of implemented changes. Educational objective: Root cause analysis is a quality improvement measure that aims to identify steps leading to a preventable adverse outcome within a system of care. It involves data collection through chart review and interviews of multiple individuals involved. References: A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers. (http://www.ncbi.nlm.nih.gov/pubmed/23367650) Applying root cause analysis to promote the medication safety of continuous drug infusions for infants. (http://www.ncbi.nlm.nih.gov/pubmed/24677005) The nature and causes of unintended events reported at ten emergency departments. (http://www.ncbi.nlm.nih.gov/pubmed/19765275)

A 74-Year-Old Man Is Brought to the Emergency Department After