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Difficulty: MediumRoot Cause Analysis and Error Investigation

A 4-year-old boy is admitted to the pediatric ward with community-acquired pneumonia. The attending physician prescribes intravenous acetaminophen for fever control, ordering the dose in milligrams. However, the ward's infusion pumps require the rate to be programmed in milliliters per hour. While calculating the volume, the primary nurse is interrupted multiple times by alarms from a neighboring room. As a result, a calculation error occurs, and the patient receives a 10-fold overdose of the medication. The error is discovered three hours later by the oncoming shift nurse. The patient is promptly treated with N-acetylcysteine and suffers no permanent harm. A root cause analysis (RCA) is convened to investigate the incident. Based on the hierarchy of safety controls, which of the following interventions is the most effective systemic action to prevent a recurrence of this specific error?

  1. Integrating the electronic health record with smart infusion pumps that automatically calculate weight-based volumes and lock out parameters exceeding standard limitsAnswer
  2. B
    Performing a failure mode and effects analysis on the pediatric ward to anticipate and mitigate future medication administration vulnerabilities
  3. C
    Instituting a new unit policy that mandates an independent double-check by a charge nurse before any intravenous medication is initiated
  4. D
    Requiring all pediatric ward nursing staff to complete a mandatory online retraining module on weight-based medication calculations
  5. E
    Issuing a formal disciplinary warning to the involved nurse to reinforce the importance of adhering to medication administration protocols

Answer

Integrating the electronic health record with smart infusion pumps that automatically calculate weight-based volumes and lock out parameters exceeding standard limits
According to the hierarchy of safety controls, the most effective interventions are those that design out the hazard by addressing latent systems issues. Forcing functions and automation (such as smart pumps with hard limits and automated calculations) are highly effective because they do not rely on human memory or vigilance. In a distracting environment, a forcing function actively prevents a user from making an error, directly mitigating the root causes of manual calculation and unit mismatch.

Step-by-Step Solution

1
Analyze the adverse event to identify the active error and latent conditions.
Active error: nurse miscalculated the dose. Latent conditions: mismatched order/pump units and cognitive overload from frequent interruptions.
To understand the root causes before selecting an appropriate corrective intervention.
2
Evaluate potential interventions using the hierarchy of safety controls.
Automation and forcing functions (smart pumps with hard limits) are identified as the strongest interventions compared to policies or training.
To select the most robust systemic solution that does not rely heavily on human vigilance.

Key Concept

Hierarchy of Safety Controls in Error Prevention
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Topics

Root Cause Analysis and Error Investigation

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