A nurse administers 10 units of regular insulin intravenously to a patient instead of the prescribed 10 units of regular insulin subcutaneously. The patient develops symptomatic hypoglycemia requiring dextrose administration. Using the Swiss cheese model of error causation, which of the following best explains how this error reached the patient?
- A)The patient failed to verify the route of administration
- B)Multiple system safeguards had gaps that aligned simultaneouslyGABARITO
- C)The pharmacy dispensed the wrong formulation of insulin
- D)The prescribing physician wrote an ambiguous order
- E)The nurse lacked adequate training in insulin administration
Explicação
The Swiss cheese model, developed by James Reason, conceptualizes errors as resulting from the alignment of holes in multiple layers of defense. No single layer is perfect; when gaps in prescribing, dispensing, administration, and monitoring align, errors reac... Ver explicação completa e trilha adaptativa →