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Question

Difficulty: MediumPatient Safety and Quality Improvement

A 68-year-old man is admitted to the hospital with acute decompensated heart failure. On his second day of admission, he is prescribed an intravenous diuretic to manage his fluid overload. The attending physician enters an order for furosemide 40 mg IV into the electronic medical record. However, the nurse accidentally administers 40 mg of famotidine IV instead. The error is discovered two hours later during a shift change handoff when the incoming nurse notes the empty famotidine vial in the patient's room. The patient is evaluated and remains hemodynamically stable, although his urine output has not increased as expected. The patient is informed of the error. The hospital's risk management team is notified. Which of the following is the most appropriate next step to prevent this type of error from occurring in the future?

  1. A
    Mandate remedial training on medication administration for the involved nurse.
  2. B
    Place the involved nurse on administrative leave pending an investigation.
  3. Convene a multidisciplinary committee to review the processes leading to the event.Answer
  4. D
    Implement a new hospital-wide policy requiring a double-check for all intravenous medications.
  5. E
    Report the incident to the state nursing board for disciplinary review.

Answer

Convene a multidisciplinary committee to review the processes leading to the event.
The most appropriate next step is to convene a multidisciplinary committee to conduct a root cause analysis (RCA). RCA is a retrospective approach used to identify the systemic vulnerabilities that led to an adverse event or near miss. It involves interviewing staff, reviewing records, and analyzing processes to find the fundamental reason the error occurred (e.g., were furosemide and famotidine stored next to each other? Do their vials look identical?). The goal is to implement systemic changes (e.g., physical separation of medications, barcode scanning) rather than punishing individuals. Punishing individuals does not prevent the next person from making the same mistake in a flawed system.

Step-by-Step Solution

1
Analyze the clinical vignette.
A medication administration error occurred (famotidine given instead of furosemide). The patient was informed, and risk management was notified.
To understand the context of the adverse event and what actions have already been taken.
2
Identify the core objective.
Determine the best systemic approach to prevent future occurrences of this specific error.
The question asks for the most appropriate next step in error prevention.
3
Evaluate the options based on quality improvement principles.
Patient safety protocols prioritize a systems-based approach (Root Cause Analysis) over individual blame.
Most medical errors are due to systemic flaws (e.g., look-alike/sound-alike medications, confusing interfaces, understaffing) rather than individual negligence.

Key Concept

Root Cause Analysis (RCA) is a retrospective, multidisciplinary process used to identify the underlying systemic reasons for a medical error, focusing on process improvement rather than individual blame.
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Topics

Patient Safety and Quality Improvement

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