A 52-year-old man is recovering on the postoperative orthopedic ward following a right total knee arthroplasty. He is prescribed subcutaneous enoxaparin for deep vein thrombosis prophylaxis. A float pool nurse inadvertently retrieves and administers regular insulin from the automated dispensing cabinet instead of enoxaparin. Shortly after the injection, the patient becomes profoundly diaphoretic and tachycardic. A point-of-care blood glucose test reveals a level of 42 mg/dL. Arrange the following steps in the most appropriate chronological sequence for managing this patient safety event, from the immediate response to long-term institutional improvement.
- 1Administer intravenous dextrose to clinically stabilize the patient.
- 2Disclose the medication administration error to the patient and family.
- 3Submit an event report into the hospital's internal safety reporting system.
- 4Conduct a formal root cause analysis to identify systemic vulnerabilities.
- 5Implement a new protocol to physically separate high-alert medications in dispensing cabinets.
Answer
The correct sequence is to first stabilize the patient, then disclose the error to the patient and family, file an internal safety report, conduct a root cause analysis, and finally implement system-level corrective actions.
The management of a medical error follows a structured sequence. The foremost priority is clinical stabilization to prevent further harm. Immediately following stabilization, the attending physician must ethically disclose the error to the patient. Next, the involved staff files an incident report into the hospital's safety system. This report alerts risk management, who then convenes a multidisciplinary team to perform a Root Cause Analysis (RCA) to identify latent system flaws. Finally, the institution implements corrective actions derived from the RCA to prevent future occurrences.
Step-by-Step Solution
Key Concept
Patient Safety Event Management Sequence