Patient Safety & Quality Improvement USMLE Step 1 Practice Question
A nurse administers 10 units of regular insulin intravenously to a patient instead of the prescribed 10 units of regular insulin subcutaneously. The patient develops symptomatic hypoglycemia requiring dextrose administration. Using the Swiss cheese model of error causation, which of the following best explains how this error reached the patient?
Answer choices
- AThe patient failed to verify the route of administration
- BMultiple system safeguards had gaps that aligned simultaneouslyCorrect answer
- CThe pharmacy dispensed the wrong formulation of insulin
- DThe prescribing physician wrote an ambiguous order
- EThe nurse lacked adequate training in insulin administration
- FThe insulin vial lacked appropriate labeling to distinguish between intravenous and subcutaneous formulations
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