Two patients with community-acquired pneumonia, Patient A and Patient B, are admitted to the intensive care unit (ICU) of a small community hospital. Blood cultures are ordered on both patients. At the start of a 12-hour day shift, an on-call senior resident who is caring for both patients receives notification from the laboratory that Patient A's blood cultures are growing gram-positive cocci in clusters. The resident enters an electronic order for intravenous vancomycin but mistakenly places the order for Patient B instead of Patient A. Two days later, Patient B experiences acute kidney injury. The nephrologist identifies the error, and vancomycin is immediately discontinued. Which of the following changes would root cause analysis most strongly support to prevent future occurrences of this error?

Question

Two patients with community-acquired pneumonia, Patient A and Patient B, are admitted to the intensive care unit (ICU) of a small community hospital.  Blood cultures are ordered on both patients.  At the start of a 12-hour day shift, an on-call senior resident who is caring for both patients receives notification from the laboratory that Patient A's blood cultures are growing gram-positive cocci in clusters.  The resident enters an electronic order for intravenous vancomycin but mistakenly places the order for Patient B instead of Patient A.  Two days later, Patient B experiences acute kidney injury.  The nephrologist identifies the error, and vancomycin is immediately discontinued.  Which of the following changes would root cause analysis most strongly support to prevent future occurrences of this error?

Quizplus · Accepted Answer

11ec25c8_d530_ba40_bc81_ff48ea72b653_MD0003_00 In this scenario, an electronic order was accidentally entered for the wrong patient, and the medication was continued for 2 days, resulting in significant nephrotoxicity. This type of wrong-patient error (WPE) occurs frequently in the use of computerized provider order entry systems. WPEs are sentinel events (ie, patient safety events resulting in death, severe temporary harm, or permanent harm). The etiology of sentinel events extends beyond individual blame, instead signifying system-level safety defects. Identification of system-level defects begins with root cause analysis (RCA), a retrospective, comprehensive, and systematic error analysis that must be performed following sentinel events. RCA uncovers the most basic causes (roots) of error, including problematic organizational processes that allow patient safety to be compromised by performance deviations (eg, human error). In this case, RCA is likely to reveal suboptimal teamwork as a basic cause of error. Suboptimal teamwork is a leading cause of sentinel events. Conducting daily interprofessional rounds (ie, involving individuals from different disciplines, such as pharmacy and nursing) improves communication and teamwork and reduces mortality in complex settings (eg, intensive care unit). Including a pharmacist and a nurse on daily rounds would have enabled collaborative oversight of patient medications and prompted quick recognition of the incorrect order. (Choice A) Didactic training may be appropriate to remedy knowledge deficiency (eg, inappropriate antibiotic selection) or in error-prone settings (eg, adoption of new electronic medical record system) but is generally inferior to hands-on, experiential learning (eg, training using team-based simulation). (Choice B) Time off or sleep breaks can address provider fatigue, a major cause of human error. This error occurred at the beginning of the resident's shift, making fatigue a less likely cause; fatigue would also not explain why the error went unnoticed for 2 days. (Choice D) Minimizing handoffs addresses transition-of-care errors (ie, care gaps or miscommunication at shift change). In this case, information was communicated to and acted on by the same resident. (Choice E) Requiring verbal approval from a specialist promotes safety, as it introduces redundancy (ie, adding multiple checkpoints) before potentially dangerous interventions. However, this step would not have addressed the root cause of this error (ie, lack of regular team-based oversight of patient care in a complex environment). Even with the specialist's approval, the order could still have inadvertently reached the wrong patient and remained undetected. Educational objective: Root cause analysis is a systematic approach that identifies fundamental, system-level factors causing error, in lieu of assigning individual blame. Interprofessional rounds (ie, involving a team of professionals from different disciplines) improve teamwork, communication, and oversight, reducing the risk of sentinel events such as wrong-patient error. References: The effect of multidisciplinary care teams on intensive care unit mortality. (http://www.ncbi.nlm.nih.gov/pubmed/20177041) Providers do not verify patient identity during computer order entry. (http://www.ncbi.nlm.nih.gov/pubmed/19086323)

Two Patients with Community-Acquired Pneumonia, Patient a and Patient B