MEDICATION ERROR Don't let a tragedy happen at your facility.

A simple medication mishap can cause unimaginable consequences. It happens more frequently than it should, but there are steps you can take to avoid a problem. The following case shows that several factors led to a medication error, and that open communication between the patient, facility and employees is essential.

The incident
A few days after a 65-year-old Oregon woman underwent successful neurosurgery, she became concerned about the anti-seizure medication she was taking following the procedure. Her son took her to the ER, where a doctor ordered an IV infusion of another anti-seizure medication.

The woman's family anticipated she would be discharged from the emergency department and able to return home quickly. Instead, their mother was given the wrong medication, which caused a cardiac arrest, leading to permanent brain damage. The patient was eventually placed on life-support and died a few days later.

The hospital began an investigation to determine how the error occurred and informed the patient's family a few days later that a medication error was to blame. The hospital initially found a pharmacy worker had prepared an IV bag with rocuronium (a paralytic) instead of fosphenytoin (an anti-seizure medication), which was ordered. The error and its catastrophic outcome were made even more complicated thanks to a series of related events.

The investigation found that after initially filling the prescription, a second pharmacy employee failed to spot the error when she checked the IV bag and vials. The IV bag was then labeled as containing the anti-seizure medication and sent to the ER, where it was administered to the woman.

Adding to the event was that during administration of the drug there was a fire alarm at the hospital. Per the hospital's protocol, the patient was left alone and the doors automatically closed to prevent any fire from spreading. The patient was not checked on until 20 minutes later, when a nurse found the woman in cardiac and respiratory arrest.

At first glance, you may want to blame the pharmacy worker who prepared the incorrect IV infusion. However, in these types of events it's important to avoid rushing to a conclusion without looking at the incident from a broader perspective. Looking for the primary cause of an event limits your ability to identify other contributing factors.

If faced with a medical error, you want to analyze and identify all of the potential reasons for the problem. Human factors, such as distractions and fatigue, similar packaging and names, staffing issues, poor communication and hand-offs may have contributed to the error. In this case, you'd want to investigate the fire alarm protocol and the administration of drugs in addition to the pharmacy error.

SUPPLY COSTS
Post Prices for Every Supply

COST-CONSCIOUS We affix prices to each supply bin so staff knows the exact costs.

We affix pricing to all supplies. This informs staff of the exact cost of items and helps them to decide when opening for a case whether to open items for "just in case" or whether to hold items until absolutely needed. Pricing transparency helps to keep supply costs down.

Lisa Waters, RN
Columbia (S.C.) Eye Surgery Center
[email protected]

Talking to the family
After a medication error, communication with the family is also important. Disclosure of a medical error is not easy, but it is, without a doubt, the right thing to do. Patients and families want to know what happened and once they get past the initial shock, will have many questions. You want to give families an honest explanation with a sincere expression of empathy.

To make open communication with the patient and family more efficient, ensure you have a designated point person who is tasked with keeping the family updated. In the case above, the hospital's chief medical officer continued to stay in contact with and provide updates to the family as the investigation went on.

Whoever communicates with the family should be careful to provide the known facts and avoid speculating or placing blame before completing an investigation. In this case, the hospital correctly waited until it confirmed the medication error before informing the family. It is okay to say, "We don't have all the answers right now, but we will be conducting a thorough investigation."

Staff suffer, too
There are other considerations besides the family following a fatal medication error. After this incident, 3 hospital employees were placed on administrative leave and provided with counseling. Experience tells us that healthcare workers are crushed when they're involved in a medical error, especially when it results in a significant injury or death. Unintentional errors have ended many healthcare careers and can lead to a lifetime of emotional distress. In these events, try to recognize the caregivers are the "second victim" and take steps to provide emotional support. You also want to look to these employees for their input on where the process failed and what can be improved.

Cases such as this one are heartbreaking on so many levels. Healthcare professionals must take every opportunity to learn from their mistakes and prevent them from reoccurring.