A root cause analysis (RCA) is conducted after a 4-year-old child in the pediatric intensive care unit mistakenly receives a 10-fold overdose of continuous intravenous morphine, resulting in respiratory arrest requiring intubation. The committee identifies several vulnerabilities and proposes multiple corrective actions based on the hierarchy of safety controls. Match each proposed corrective action to its correct classification within the hierarchy of safety interventions based on its anticipated effectiveness.
- Configuring the smart infusion pump software with a 'hard stop' that physically prevents programming a morphine rate exceeding the maximum weight-based pediatric limit.Forcing function (Strong safety intervention)
- Removing all concentrated opioid vials from the unit's automated dispensing cabinets and stocking only standard-concentration, pre-mixed syringes.Elimination and substitution (Strong safety intervention)
- Implementing a single, hospital-wide weight-based order set for opioid infusions, replacing the diverse protocols previously used across different wards.Standardization (Intermediate safety intervention)
- Instituting a policy that requires two nurses to separately perform the dose calculation and verify the pump settings before starting the infusion.Independent double-check (Weak safety intervention)
- Mandating an annual 1-hour continuing medical education module for all clinical staff focusing on high-risk medication administration and decimal errors.Education and training (Weak safety intervention)
Cevap
Pump hard stop matches with Forcing function; Removing vials matches with Elimination; Single order set matches with Standardization; Two-nurse verification matches with Independent double-check; Annual module matches with Education and training.
The hierarchy of effectiveness of risk-reduction strategies is a fundamental concept in patient safety. Strong interventions physically prevent errors (forcing functions) or remove the hazard entirely (elimination). Intermediate interventions reduce the likelihood of error by optimizing human factors (standardization, simplification). Weak interventions attempt to change human behavior directly through rules, warnings, education, or double-checks, which consistently fail under high-stress clinical conditions.
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Anahtar Kavram
The hierarchy of safety controls ranks interventions by their effectiveness. Strong interventions (e.g., forcing functions, elimination) do not rely on human memory. Intermediate interventions (e.g., standardization) streamline processes. Weak interventions (e.g., education, rules, double-checks) rely heavily on human vigilance.