Pharmacy PEBC Practice Exam

An attending physician used the computerized practitioner order entry (CPOE) system in the hospital to order a single bolus infusion of 1 L Ringer’s lactate solution to be administered over 1 hour to a patient. The evening pharmacist validated the electronic order without a stop date, and the nurse verified the pharmacist’s entry. The medication administration record displayed an ongoing order of 1 L Ringer’s lactate to be given every hour, which the nurses administered. The patient received an excess 9 L of Ringer’s lactate in error. The unit pharmacist detected the error in the morning and notified the physician. The patient had pleural effusions requiring transfer to the ICU. The pharmacist submits an incident report in the hospital’s confidential internal safety incident reporting system. Whose identity is the most appropriate to be documented in this report?

1. The attending physician

2. The pharmacist who validated the order

3. The nurse who verified the order

4. The nurses who administered the Ringer’s lactate

The correct answer is: The attending physician

The attending physician is responsible for ordering the medication, and the error occurred due to the lack of a stop date on the order. While the pharmacist and nurse were involved in the medication process, the ultimate responsibility lies with the physician who ordered it. Additionally, the pharmacist and nurse were following standard procedures and protocols. Therefore, the attending physician's identity is the most appropriate to be documented in the incident report. Choosing any of the other options would not accurately reflect the individual responsible for the error. It is important to document the correct identity to prevent similar errors in the future and ensure accountability.