A Patient Dies in the Hospital After a Rare but Fatal

question 4

Multiple Choice

A patient dies in the hospital after a rare but fatal adverse event related to a drug-drug interaction.  In response, the hospital implements a more comprehensive database of drug-drug interactions in its computerized order entry system.  The updated database increases the number of recognized drug interactions from 60,000 to 200,000.  A year later, however, the quality improvement team finds that the number of prescribed drugs with high-risk interactions has increased since the database update.
Which of the following is the most likely explanation for this finding?

• A)Alert fatigue
• B)Increased workload
• C)Overutilization
• D)Poor interoperability
• E)Risk homeostasis

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