Examkin

Question

Difficulty: MediumPatient Safety and Quality Improvement

A hospital's quality improvement committee is reviewing recent incident reports to improve patient safety. During the review, they analyze a near-miss event in which an infant was almost given intravenous acyclovir after a triage nurse misinterpreted neonatal cephalic pustulosis as a serious infectious rash. They also review an adverse event where a 45-year-old man with a documented severe penicillin anaphylaxis allergy received intravenous piperacillin-tazobactam. Root cause analysis of the second event reveals that the physician was experiencing alert fatigue and bypassed the electronic health record (EHR) warning. The committee decides to prioritize systemic interventions to prevent the medication error from recurring. Which of the following proposed interventions is most likely to be effective?

  1. Disabling the ability to override severe allergy warnings in the electronic health recordAnswer
  2. B
    Instituting an antibiotic stewardship protocol that restricts piperacillin-tazobactam to infectious disease specialists
  3. C
    Implementing a mandatory retraining program for all clinical staff on the identification of benign pediatric skin conditions
  4. D
    Enforcing a policy that temporarily suspends the admitting privileges of physicians who bypass severe allergy alerts
  5. E
    Requiring nurses to verbally confirm all overridden medication alerts with the prescribing physician prior to administration

Answer

The most effective intervention is disabling the ability to override severe allergy warnings in the electronic health record.
In the field of quality improvement, interventions are ranked by their effectiveness. At the bottom are weak interventions that rely on human performance (education, training, policies, and punitive measures). Intermediate interventions include checklists, increased staffing, and software enhancements. At the top of the hierarchy are strong interventions, primarily forcing functions (hard stops) and physical constraints. Disabling the ability to override a severe allergy alert is a forcing function because it completely removes the physician's ability to make the active error, regardless of their level of alert fatigue or distraction. Therefore, it is the most effective systemic intervention.

Step-by-Step Solution

1
Identify the core problem based on the root cause analysis provided in the stem.
The core problem is that the physician experienced 'alert fatigue' and bypassed a critical allergy warning, leading to patient harm.
Accurately identifying the root cause prevents the selection of interventions that address irrelevant or secondary issues.
2
Evaluate the proposed interventions against the hierarchy of effectiveness in patient safety.
Education/policies are weak; reminders/double-checks are intermediate; forcing functions/hard stops are strong.
The committee needs the 'most likely to be effective' intervention, which directly correlates to the highest level on the hierarchy of effectiveness.
3
Select the option that represents a forcing function for the specific root cause identified.
Disabling the ability to override the alert is a forcing function (hard stop) that mathematically guarantees the error cannot be repeated via the same pathway.
Forcing functions do not rely on human memory, vigilance, or compliance, making them the gold standard in error prevention.

Key Concept

The Hierarchy of Intervention Effectiveness in Patient Safety
Rate this question

Topics

Patient Safety and Quality Improvement

More questions from this topic