A 45-year-old man undergoes an outpatient punch biopsy of a suspicious pigmented skin lesion. The biopsy specimen is sent to an external pathology laboratory. Two weeks later, the pathology report confirming invasive melanoma is faxed back to the primary care clinic. However, an administrative assistant accidentally scans and indexes the report into the electronic health record of another patient with a similar name. The ordering physician never sees the result. Eight months later, the 45-year-old man presents to the emergency department with new-onset seizures and is found to have brain metastases originating from melanoma. The clinic's quality improvement committee convenes a multidisciplinary team to investigate this sentinel event. Following a root cause analysis, the team proposes several corrective actions. Which of the following is the most effective systems-level intervention to prevent a recurrence of this specific error?
- AConcluding the investigation early by mandating an annual training module on proper document indexing for all administrative clinic staff
- BInstituting a manual sign-off sheet to ensure no steps are omitted when transitioning paper reports into the electronic health record system
- Implementing an automated bidirectional electronic interface that directly imports and matches pathology results to the correct patient chartAnswer
- DConducting a failure mode and effects analysis to determine exactly why the administrative assistant scanned the report into the wrong chart
- EAssuming the error resulted from the clerk's anchoring bias and placing a warning letter in their employment file to enforce accountability