A 19-Year-Old Man Is Admitted with Delusions, Hallucinations, and Disorganized

A 19-year-old man is admitted with delusions, hallucinations, and disorganized behavior.  He is diagnosed with schizophrenia, and the physician writes an order to begin aripiprazole "2.0" mg.  The patient mistakenly receives 20 mg aripiprazole instead of 2 mg.  This order is overlooked during the pharmacy review process, and the nurse fails to question it before administering aripiprazole to the patient.  Which of the following is the most effective intervention to reduce this type of error?

A) Confirm dosage with the patient prior to administration
B) Educate physicians to avoid use of trailing zeros
C) Employ computerized systems to flag inappropriate medication orders
D) Remind physicians to be careful with decimal point placement
E) Require 2 nurses to check medication orders
F) Require 2 pharmacists to check all orders

Correct Answer:

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