A 54-year-old woman is admitted to the medical ward for treatment of an acute pulmonary embolism. Due to a programming error on the smart infusion pump, she receives a rapid bolus of intravenous heparin instead of the intended continuous maintenance infusion. Two hours later, the error is discovered when the patient develops severe epistaxis and gingival bleeding. Her activated partial thromboplastin time (aPTT) is >150 seconds. Arrange the following steps in the most appropriate chronological order for managing and responding to this adverse event, from the most immediate action to long-term system improvement.
- 1Discontinue the heparin infusion and administer intravenous protamine sulfate.
- 2Disclose the medication administration error to the patient and explain the corrective actions taken.
- 3Convene a multidisciplinary committee to perform a root cause analysis of the event.
- 4Implement an institutional protocol requiring independent double-checks for high-alert medication infusions.
Cevap
The correct chronological sequence for managing this adverse event is: 1) Discontinue the heparin infusion and administer intravenous protamine sulfate, 2) Disclose the medication administration error to the patient and explain the corrective actions taken, 3) Convene a multidisciplinary committee to perform a root cause analysis of the event, and 4) Implement an institutional protocol requiring independent double-checks for high-alert medication infusions.
The management of a severe adverse event follows a structured progression that prioritizes immediate patient safety, followed by ethical communication, and concludes with system-level quality improvement. The physician must first arrest the immediate harm by stabilizing the patient clinically. Once the patient is safe, the physician must uphold the ethical duty of candor by disclosing the error to the patient. Subsequently, the hospital initiates a root cause analysis to understand why the error occurred. Finally, the findings from the root cause analysis are used to implement robust, system-wide safeguards to prevent future occurrences.
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Anahtar Kavram
The management of a medical error follows a structured sequence: immediate patient stabilization, prompt disclosure to the patient, retrospective investigation via Root Cause Analysis (RCA), and proactive implementation of system-level preventive measures.