Over the next several months, there are more cases in which expired medications fail to be renewed. Finally, a patient on intravenous dobutamine for decompensated heart failure does not receive the medication for 6 hours and experiences worsening of her condition, with resulting hypotensive shock. Hospital administration convenes a committee to address this incident. Which of the following is the most appropriate next step in addressing this problem?

Question

Over the next several months, there are more cases in which expired medications fail to be renewed.  Finally, a patient on intravenous dobutamine for decompensated heart failure does not receive the medication for 6 hours and experiences worsening of her condition, with resulting hypotensive shock.  Hospital administration convenes a committee to address this incident.  Which of the following is the most appropriate next step in addressing this problem?

Quizplus · Accepted Answer

Addressing medication errors promptly is important in solving recurrent problems and preventing further harm to patients. The first step of the committee should be to conduct a step-by-step analysis of what occurred and why. Typically, the best approach is to employ a root cause analysis, which aims to identify what, how, and why an undesirable outcome occurred. The first step in a root cause analysis involves collecting data to obtain complete information about the event or events. This involves interviewing multiple staff members involved to understand why and how the adverse outcomes occurred. For example, interviews may uncover root causes such as understaffing in the pharmacy stemming from budget cuts or a hostile hierarchical culture that led nursing staff to be reluctant to point out problems to the medical staff. Only when investigators determine why an event occurred can they recommend specific corrective measures to prevent future occurrences (Choices A and B). (Choice C) Increasing the hospital's risk management staffing may improve its ability to handle potential lawsuits but would not directly address the recurrent issue of not recognizing expired medication orders. (Choice E) Although interviewing the patients involved can sometimes yield information about the course of events, this is not typically a key step in conducting a root cause analysis. The most important step is interviewing staff members on the units where these incidents occurred. Educational objective: Root cause analysis is a quality improvement measure that identifies what, how, and why a preventable adverse outcome occurred. The first step involves collecting data mainly through interviewing multiple individuals involved in the steps leading to the outcome. __________ References: Medication errors: an overview for clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/24981217)

Over the Next Several Months, There Are More Cases in Which