Patient Safety & Quality Improvement USMLE Step 1 Practice Question
A 38-year-old woman with newly diagnosed atrial fibrillation presents to the anticoagulation clinic to initiate warfarin therapy. Vital signs are stable: BP 118/76, HR 102, RR 16, temperature 37.2°C. The patient is prescribed warfarin 5 mg daily. Before taking the first dose at home, the patient discovers the pharmacy dispensed 50 mg tablets instead of 5 mg tablets—a 10-fold overdose. The patient contacts the clinic immediately without taking any medication. INR is found to be 2.3 (therapeutic range 2-3). The hospital's quality and patient safety team initiates a comprehensive root cause analysis of this medication error. Which of the following represents the most appropriate focus for this quality improvement initiative?
Answer choices
- ATerminate the dispensing pharmacist and implement a "name and shame" protocol to prevent similar errors by other staff members
- BRequire the patient to sign an acknowledgment form accepting liability for medication verification before future prescriptions are filled
- CImplement automated dose verification alerts that flag prescriptions for warfarin exceeding 10 mg daily before dispensing
- DConduct a systems-level analysis to identify process failures, communication breakdowns, and latent conditions that allowed the error to reach the patientCorrect answer
- EIncrease malpractice insurance premiums and establish a financial penalty system to incentivize individual pharmacist accountability
- FRapidly implement a new pharmacy workflow protocol based on intuition about likely causes without further investigation to demonstrate immediate responsiveness
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