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Difficulty: MediumPatient Safety Culture and Reporting Systems

During a busy night shift on a medical-surgical floor, a cross-covering nurse responds to an infusion pump alarm for a patient being treated for a pulmonary embolism. While attempting to silence the alarm, the nurse inadvertently alters the continuous intravenous heparin rate, increasing it from 1,200 units/hour to 12,000 units/hour. Several hours later, the patient becomes hypotensive (85/55 mm Hg) and develops gross hematuria. The attending physician immediately identifies the dosing error, halts the infusion, and administers intravenous fluids alongside protamine sulfate. Following these interventions, the patient regains hemodynamic stability and the bleeding ceases. The clinical team holds an open discussion with the patient and his family to transparently disclose the medication error. Which of the following is the most appropriate next administrative step for the healthcare team to prevent future occurrences of this type of event?

  1. Submit a formal incident report to the institution's safety reporting system to initiate a system-level review.Answer
  2. B
    Conclude the event review by issuing a formal reprimand to the cross-covering nurse for the programming error.
  3. C
    Document an absolute contraindication to heparin in the patient's electronic medical record.
  4. D
    Order pharmacogenomic testing to evaluate for altered drug metabolism and potential interactions.
  5. E
    Delay filing the incident report until the patient is discharged to ensure the final clinical outcome is documented.

Answer

The most appropriate next step is to submit a formal incident report to the institution's safety reporting system to initiate a system-level review.
The correct answer addresses the necessity of a nonpunitive, system-wide approach to medical errors. In a Just Culture, adverse events must be promptly reported to the institution's safety reporting system. This action triggers a multidisciplinary investigation, such as a Root Cause Analysis (RCA), which looks beyond the active failure (the nurse pressing the wrong button) to identify latent errors (e.g., confusing pump interfaces, inadequate staffing, or poor handoff protocols).

Step-by-Step Solution

1
Identify the primary clinical event
A 10-fold medication dosing error occurred due to a pump programming mistake, causing an adverse event (patient harm).
Understanding the nature of the error dictates the appropriate safety and clinical response.
2
Confirm patient stabilization and disclosure
The patient has been hemodynamically stabilized, and the error has been disclosed to the patient and family.
Immediate patient safety and ethical transparency are the highest priorities following a medical error.
3
Determine the appropriate systemic action
The event must be formally documented in the hospital's reporting system.
Incident reporting triggers an institutional review to identify latent system flaws and prevents future occurrences in a Just Culture framework.

Key Concept

Patient Safety Culture and Reporting Systems
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Topics

Patient Safety Culture and Reporting Systems

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