Patient Safety & Quality Improvement USMLE Step 1 Practice Question
A hospital's morbidity and mortality conference reviews a case in which a patient died after receiving a tenfold overdose of heparin. The investigation reveals that the pharmacy stocked two different concentrations of heparin vials in the same medication drawer. The concentrations differed by a factor of ten, and the vials were similar in appearance. Which of the following is the most effective system-level intervention to prevent recurrence?
Answer choices
- AEducate nursing staff on the different heparin concentrations
- BSeparate the two heparin concentrations into different storage locations with distinct labelingCorrect answer
- CImplement barcode scanning for medication administration
- DImplement mandatory double-checks for all heparin doses
- ERequire pharmacists to personally deliver all heparin doses to the bedside
- FIncrease the frequency of pharmacy audits to identify medication storage errors
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