A hospital quality improvement committee is reviewing a recent medication administration event. A nurse working on a busy telemetry unit administered 10 mg of intravenous morphine instead of the ordered 5 mg. The patient experienced mild sedation but remained hemodynamically stable and required no reversal agents. Subsequent investigation reveals that 5 mg/mL and 10 mg/mL morphine vials, which have nearly identical packaging, were stocked in adjacent compartments within the unit's automated medication dispensing system. The nurse selected the incorrect vial during a period of high clinical volume. Which of the following is the most appropriate next step to prevent a recurrence of this event?
- Implement physical separation and distinct visual alerts for the two medication concentrations within the dispensing cabinetCevap
- BIssue a formal disciplinary warning to the nurse for failing to verify the medication dosage
- CRequire the involved nurse to complete remedial training on standard medication administration protocols
- DRestrict the nurse from administering high-alert medications until a probationary period is completed
- EReassign the nurse to a lower-acuity unit with less frequent medication administration requirements
Cevap
Implement physical separation and distinct visual alerts for the two medication concentrations within the dispensing cabinet.
The correct answer identifies a strong, system-level intervention. When an error occurs due to latent system flaws, such as identical packaging and adjacent storage of different medication concentrations, the most effective preventative strategy is to redesign the system. Physically separating the medications and adding distinct visual alerts directly mitigates the underlying risk factors.
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Anahtar Kavram
In the event of a medical error, the most effective preventative measures involve systemic process redesign (e.g., physical separation of look-alike medications) rather than individual blame or punitive action.