The audit identifies deviations from medication safety protocols, with the goal of prioritizing investigation based on potential or actual harm. Patient safety principles prioritize issues that directly threaten patient safety, such as failures in critical safety checks or adverse outcomes.
Option A (Patient D): No documentation of medication administration is a concern, as it affects record accuracy, but no adverse reaction occurred, suggesting no immediate harm. This is a lower priority.
Option B (Patient B): This is the correct answer. Patient B had no confirmation of allergies prior to administration and experienced an adverse reaction. The NAHQ CPHQ study guide states, “Failure to verify allergies is a critical safety lapse that can lead to adverse drug events, requiring immediate investigation” (Domain 1). The combination of a process failure (no allergy check) and an adverse outcome (reaction) makes this the highest priority.
Option C (Patient C): Delayed administration (not within 1 hour) is a process issue, but no adverse reaction occurred, reducing its urgency compared to cases with harm.
Option D (Patient A): All safety checks were followed, but an adverse reaction occurred. This suggests the reaction may not be related to a process failure, making it less urgent than a preventable error.
CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.3, “Prioritize safety issues based on risk and harm,” emphasizes focusing on incidents with actual or potential harm, particularly those involving critical safety failures like allergy verification. The NAHQ study guide notes, “Adverse drug events linked to process failures, such as not checking allergies, are high-priority for investigation to prevent recurrence” (Domain 1).
Rationale: Patient B’s case involves a failure to confirm allergies (a critical safety step) and an adverse reaction, indicating a preventable error with harm, aligning with CPHQ’s focus on prioritizing high-risk safety lapses.
[Reference: NAHQ CPHQ Study Guide, Domain 1: Patient Safety, Objective 1.3., , , ]
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