The increasing medication error rate despite a stable bar coding system suggests a human or process-related issue, as equipment and medications are unchanged.
Option A (Overdue preventive maintenance for bar code scanners): Maintenance issues could cause scanning failures, but the question states the system has been in place for 14 months with no mention of technical issues, making this less likely.
Option B (Shared computers used by nurses and physicians in clinic): Shared computers may cause workflow inefficiencies but are unlikely to directly cause medication errors, as the bar coding system prompts specific safety checks.
Option C (Visual alarm fatigue experienced by nurses administering medications): This is the correct answer. The NAHQ CPHQ study guide states, “Alarm fatigue occurs when clinicians become desensitized to frequent alerts, leading to missed safety checks and errors” (Domain 1). The pop-up screens in the bar coding system likely generate alerts, and over time, clinicians may bypass these due to fatigue, increasing errors.
Option D (Mislabeling of the medication by the drug manufacturer): Mislabeling is unlikely, as the medications are unchanged, and errors would likely have been detected earlier in the 14-month period.
CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.4, “Identify and mitigate human factors contributing to errors,” includes alarm fatigue as a common cause of medication errors. The NAHQ study guide notes, “Alarm fatigue is a significant patient safety risk in systems with frequent electronic alerts, leading to errors in medication administration” (Domain 1).
Rationale: Alarm fatigue explains the increasing errors in a stable system, as clinicians may ignore or bypass pop-up alerts, a known safety risk in CPHQ’s patient safety framework.
[Reference: NAHQ CPHQ Study Guide, Domain 1: Patient Safety, Objective 1.4., , , ]
