Question

A 68-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy presents to the emergency department with acute dyspnea, hypoxemia, and diffuse wheezing. The emergency physician immediately diagnoses a COPD exacerbation, orders systemic corticosteroids and bronchodilators, and places the patient on noninvasive positive pressure ventilation. Due to severe department overcrowding, the patient is rapidly handed off to the internal medicine night team. The handoff note simply states, "Severe COPD exacerbation, responding to initial therapy." At the time of transfer, the chest x-ray and B-type natriuretic peptide (BNP) results are still pending. The night team accepts the handoff without independently reviewing the electronic health record (EHR). Two hours later, the patient rapidly deteriorates and requires endotracheal intubation for acute decompensated heart failure. A subsequent review reveals the BNP was 1,450 pg/mL and the x-ray showed severe pulmonary edema, but accessing these results required navigating through multiple poorly labeled EHR submenus. A root cause analysis (RCA) is convened, identifying cognitive anchoring by the emergency physician, diagnostic momentum during the handoff, and poor EHR usability as key contributors. Which of the following proposed interventions represents the highest-reliability strategy to prevent similar events?