Over the Next Several Months, There Are More Cases in Which

Over the next several months, there are more cases in which expired medications fail to be renewed.  Finally, a patient on intravenous dobutamine for decompensated heart failure does not receive the medication for 6 hours and experiences worsening of her condition, with resulting hypotensive shock.  Hospital administration convenes a committee to address this incident.  Which of the following is the most appropriate next step in addressing this problem?

A) Create an alert system in the electronic medical record to notify physicians when orders expire
B) Have a second pharmacist double-check expired orders
C) Increase the hospital's risk management staffing
D) Interview pharmacy, nursing, and medical staff on the units where this occurred
E) Interview the patients who experienced adverse outcomes from these medication errors

Correct Answer:

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