Patient Safety & Quality Improvement USMLE Step 1 Practice Question
A 55-year-old man with type 2 diabetes mellitus is started on metformin 1000 mg twice daily by his primary care physician for glycemic control. His baseline serum creatinine is 0.9 mg/dL. Six weeks later, he presents to the emergency department with fatigue and dyspnea. Laboratory studies reveal acute kidney injury with serum creatinine of 3.2 mg/dL and elevated lactate of 5.2 mmol/L (normal <2). Chart review reveals that the patient underwent a contrast-enhanced CT abdomen 3 weeks prior to symptom onset. The radiology report was entered into the electronic health record but did not generate an automated alert to the prescribing physician's inbox. No manual dose adjustment or discontinuation of metformin was documented. Which of the following best describes the type of error that contributed to this adverse event?
Answer choices
- ASlip errorāthe provider had appropriate knowledge of metformin-associated lactic acidosis (MALA) but failed to review the imaging report due to inattention
- BLatent systems errorāfailure of clinical decision support and electronic health record integration to flag a contraindication and alert the providerCorrect answer
- CActive error due to provider negligenceāthe physician intentionally disregarded the contrast administration and chose not to adjust therapy
- DMistakeāthe provider lacked knowledge that contrast-induced nephropathy increases metformin toxicity risk
- ELapse errorāthe provider temporarily forgot metformin's renal clearance mechanism during the prescribing encounter
- FCommunication failureāthe radiologist failed to contact the physician directly by telephone to report the contrast administration
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