More incidents of expired drugs not being renewed are expected in the coming months. Finally, a woman receiving intravenous dobutamine for decompensated heart failure does not get the drug for 6 hours, causing her condition to deteriorate and ultimately in hypotensive shock. The hospital management forms a committee to investigate this occurrence. Which of the following is the best next step in resolving this issue?

Question

Quizplus · Accepted Answer

Eductional Objective: Addressing medication mistakes as soon as possible is critical for resolving recurring issues and minimizing further harm to patients. The committee's first step should be to perform a step-by-step investigation of what happened and why. A root cause analysis, which seeks to uncover what, how, and why an unpleasant outcome happened, is usually the best technique.
The first stage in doing a root cause analysis is to collect data in order to get thorough information about the occurrence or events. This entails interviewing many staff employees to determine why and how the negative consequences happened. Interviews, for example, may reveal core issues such as understaffing in the pharmacy due to budget cuts or a hostile hierarchical structure that prompted nursing staff to be hesitant to report concerns to the medical personnel. Only once investigators have determined the cause of an event can they offer precise remedial steps to avoid future occurrences.

More Incidents of Expired Drugs Not Being Renewed Are Expected