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Difficulty: EasyPatient Safety and Quality Improvement

A 65-year-old man is admitted to the hospital for treatment of community-acquired pneumonia. On his second day of admission, he inadvertently receives a 10-fold higher dose of regular insulin than prescribed. The error occurred because the nurse misread the concentration on the vial, which had packaging very similar to a different medication. The patient rapidly develops diaphoresis and tachycardia, and his point-of-care blood glucose level is 42 mg/dL. He is promptly treated with intravenous dextrose and fully recovers without any permanent sequelae. The incident is immediately reported to the hospital's quality and safety committee. Which of the following is the most appropriate next step in managing this event?

  1. A
    Suspend the nurse who administered the incorrect medication dose
  2. B
    Place a permanent warning in the involved nurse's employment file
  3. C
    Issue a formal reprimand to the pharmacist who dispensed the vial
  4. Convene a multidisciplinary team to perform a root cause analysisAnswer
  5. E
    Reassign the involved nurse to a non-clinical administrative role

Answer

The most appropriate next step is to convene a multidisciplinary team to perform a root cause analysis.
Medical errors, particularly medication errors, are most often the result of systemic flaws rather than individual negligence. The Swiss Cheese Model of medical errors illustrates that multiple system failures must align for an error to reach the patient. The most appropriate next step after an adverse event or sentinel event is to perform a root cause analysis (RCA). An RCA is a retrospective, multidisciplinary process that identifies the underlying systemic factors contributing to the error (e.g., similar packaging, inadequate staffing, poor lighting, lack of double-check protocols) rather than assigning blame to an individual provider.

Step-by-Step Solution

1
Identify the type of medical incident that occurred.
A medication administration error occurred due to look-alike packaging, resulting in patient harm (hypoglycemia) that was successfully treated.
Understanding the nature of the error is required to determine the appropriate institutional response.
2
Determine the optimal approach to medical errors in a hospital setting.
Hospitals should employ a systems-based approach rather than a punitive approach, recognizing that errors are usually the result of multiple system failures.
A punitive culture decreases error reporting and leaves the dangerous system uncorrected.
3
Select the appropriate formal process to investigate systemic errors.
Root cause analysis (RCA) is the standard retrospective process used to identify systemic vulnerabilities after an adverse event.
RCA involves a multidisciplinary team and is the correct management step for this incident.

Key Concept

Root Cause Analysis (RCA) and Systems-Based Practice
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Topics

Patient Safety and Quality Improvement

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