New-onset Heart Failure in Patient Safety, Preventive & Ethics — 45yo Man | Ethics | SMLE Q#1644
SMLE Question #1644
Patient Safety, Preventive & Ethics
Ethics
Last updated: February 2026
A 45-year-old man recently emigrated from a malaria-endemic region is admitted with new-onset heart failure. On admission, his medication history is incomplete. He is prescribed IV digoxin via computerized order entry; the pharmacy dispenses it and a nurse administers it. Shortly after the dose, he develops a malignant arrhythmia and deteriorates. Review later finds he had been taking oral quinidine obtained abroad that was not documented. Who bears primary responsibility for this medication error?
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