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Difficulty: MediumPatient Safety and Quality Improvement

A patient arrives at the emergency department following a high-speed motor vehicle collision. Upon arrival, the patient's blood pressure is 80/40 mm Hg and heart rate is 130/min. The covering physician immediately orders an abdominal and pelvic computed tomography (CT) scan to evaluate for internal hemorrhage. While being transported to the radiology suite, the patient experiences cardiopulmonary arrest and cannot be resuscitated. Following this sentinel event, a multidisciplinary committee convenes to perform a root cause analysis and implement preventative measures. The investigation reveals that the physician bypassed the standard trauma algorithm due to high patient volume and cognitive overload. Which of the following is the most appropriate recommendation from the committee to prevent this specific type of error?

  1. Implementing an electronic health record hard-stop that prevents ordering a CT scan for hypotensive trauma patients until a FAST exam is documentedAnswer
  2. B
    Placing the involved physician on administrative leave pending a complete review of their clinical decision-making history
  3. C
    Establishing a departmental protocol to ensure CT imaging is completed within 10 minutes of arrival for all hemodynamically unstable trauma patients
  4. D
    Assigning a dedicated critical care nurse to accompany all hemodynamically unstable trauma patients during transport to the radiology suite
  5. E
    Requiring the emergency department medical director to manually review and approve all diagnostic imaging orders prior to patient transport

Answer

Implementing an electronic health record hard-stop that prevents ordering a CT scan for hypotensive trauma patients until a FAST exam is documented.
This intervention correctly addresses the clinical error (inappropriately transporting a hemodynamically unstable trauma patient to the CT scanner) by implementing a high-reliability, systems-based solution. An electronic health record hard-stop acts as a forcing function, physically or procedurally preventing the user from making an error while simultaneously guiding them toward the correct clinical action (FAST exam). This approach mitigates the risk of cognitive overload and standardizes care without relying on individual memory or vigilance.

Step-by-Step Solution

1
Analyze the clinical scenario to identify the root medical error.
The physician ordered a CT scan for a hemodynamically unstable trauma patient. Unstable patients should instead undergo a FAST exam or proceed directly to exploratory laparotomy.
Recognizing the exact clinical error is essential for designing an appropriate, targeted systemic intervention.
2
Evaluate the proposed interventions using the hierarchy of effectiveness in patient safety.
Patient safety prioritizes system-level interventions (forcing functions, automation) over human-level interventions (education, policies, punitive actions).
Systemic vulnerabilities, such as cognitive overload and high patient volume, caused the error, so systemic redesign is required to prevent recurrence.
3
Select the intervention with the highest reliability.
An electronic health record hard-stop is a forcing function that directly prevents the unsafe action while guiding the provider to the correct action.
Forcing functions are the strongest level of error reduction because they do not rely on human memory or vigilance.

Key Concept

Systems-Based Practice: Forcing Functions and Error Prevention
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Topics

Patient Safety and Quality Improvement

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