Examkin

Soru

Zorluk: Çok zorRoot Cause Analysis and Error Investigation

A 62-year-old man with a documented history of severe asthma is admitted to the telemetry unit. During a shift change, the cross-covering night physician receives a page regarding the patient's new-onset tachycardia (heart rate of 135/min). While simultaneously managing two other unstable patients, the physician quickly enters an order for intravenous propranolol. A pop-up alert appears in the electronic medical record (EMR) warning of a medication-disease interaction. Experiencing alert fatigue from numerous daily low-priority warnings, the physician clicks 'override' without reading the text. The night nurse, assuming the physician evaluated the risk, administers the medication. The patient subsequently develops severe bronchospasm, requiring transfer to the intensive care unit for mechanical ventilation.

A multidisciplinary committee is convened to investigate this sentinel event.

Which of the following committee recommendations represents the most effective systems-based intervention to prevent a recurrence of this specific error?

  1. A
    Mandate that the involved physician and nurse complete a targeted educational module detailing the absolute contraindications of beta-blocker therapy in reactive airway disease
  2. B
    Discontinue the current retrospective review and immediately initiate a Failure Mode and Effects Analysis (FMEA) to evaluate the telemetry unit's overall medication administration workflow
  3. Implement an automated, hard-stop forcing function within the electronic medical record that prevents the prescription of non-cardioselective beta-blockers for any patient with a documented asthma diagnosisCevap
  4. D
    Document that the adverse event was exclusively the result of the availability heuristic, as the physician focused only on the immediate tachycardia rather than the patient's underlying comorbidities
  5. E
    Establish a hospital-wide policy requiring nurses to perform a secondary, unstructured verbal sign-out for every medication order placed during a shift transition

Cevap

Implement an automated, hard-stop forcing function within the electronic medical record that prevents the prescription of non-cardioselective beta-blockers for any patient with a documented asthma diagnosis.
The correct answer proposes a hard-stop forcing function, which is categorized as a 'strong' systems-based intervention. In the hierarchy of corrective actions developed by human factors engineering, strong interventions physically or digitally prevent a user from making an error, regardless of their cognitive state, fatigue, or vigilance. By implementing a hard stop in the EMR that blocks the order entirely, the system removes the vulnerability of alert fatigue where clinicians reflexively bypass warnings.

Adım Adım Çözüm

1
Analyze the nature of the error described in the vignette.
The error is an active failure (administering a contraindicated medication) facilitated by latent system failures, specifically alert fatigue and high cognitive load.
Understanding the root causes of the error is required to select the most appropriate corrective action.
2
Evaluate the hierarchy of effectiveness for corrective actions in patient safety.
Strong interventions (forcing functions, physical plant changes) are more effective than intermediate (checklists, standardization) or weak (policies, retraining, education) interventions.
Root cause analysis committees must prioritize the strongest possible intervention to prevent error recurrence.
3
Select the option that represents a strong systems-level intervention.
A hard-stop forcing function in the EMR is a strong intervention that directly mitigates alert fatigue.
Unlike education or unstructured policies, a forcing function does not rely on human memory or vigilance to be effective.

Anahtar Kavram

Hierarchy of Corrective Actions in Root Cause Analysis
Tahmini Süre:2m 0s
Bu soruyu puanla

Konular

Root Cause Analysis and Error Investigation

Bu konudan daha fazla soru