A 68-year-old man with a history of severe benign prostatic hyperplasia and recurrent urinary retention is admitted to the general medical floor for an acute exacerbation of chronic obstructive pulmonary disease. He is appropriately prescribed bronchodilators and systemic corticosteroids. On the first night of admission, the patient complains of severe insomnia. The cross-covering physician orders oral diphenhydramine as needed for sleep, overlooking the patient's history of benign prostatic hyperplasia. The hospital's electronic health record system does not generate an interaction warning because the patient's prostate diagnosis was documented only in free-text clinical notes from a previous admission and was never added to the standardized active problem list. The night nurse subsequently administers the diphenhydramine. Six hours later, the patient develops painful acute urinary retention, necessitating the urgent insertion of a Foley catheter. Which of the following provides the most accurate patient safety classification of the factors and outcomes in this clinical incident?
- The physician's prescribing choice is an active error, the electronic health record's inability to read free-text data is a latent error, and the clinical outcome is a preventable adverse event.Answer
- BThe clinical outcome is an unpreventable adverse event because diphenhydramine is a standard-of-care sleep aid that lacks absolute pharmacologic contraindications in patients with pulmonary disease.
- CThe incident is a near miss that primarily resulted from the physician's premature closure of the differential diagnosis when evaluating the patient's nighttime restlessness.
- DThe incident constitutes a sentinel event driven by incorrect test sequencing, as a post-void residual bladder ultrasound was omitted prior to medication administration.
- EThe nurse's administration of the medication represents a latent error resulting from the patient's inappropriate disposition to a general floor instead of a higher-acuity step-down unit.