Tuesday, May 05, 2009

Calling out the near miss

A story posted by Margaret Bernier, in our Health Care Quality Department, to provide lessons learned from our BIDMC SPIRIT program [Addendum on May 7: Margaret graciously tells me that the article was actually prepared by Pat Folcarelli and Andrew Zaglin]:

On a busy shift in one of our ICU’s, a Staff Nurse was tending to a patient who had an order for 2 grams Magnesium Sulfate. The Nurse accessed the automated medication dispensing system to retrieve the medication, housed in its own specific bin. Immediately, the nurse sensed that the medication bag containing the drug was slightly heavier than usual, but on first glance the color and look of the label was exactly what she was used to seeing for 2 grams Magnesium.In conducting the essential steps of medication administration at that time (right medication, right dose, right time, right route, right patient), she discovered that the medication was labeled as 4 grams Magnesium and not 2 grams.

The Nurse immediately reported this to the Clinical Pharmacist and her Nurse Manager. The Pharmacy immediately investigated this concern, and made a complete sweep of the location of Magnesium Sulfate in the Medical Center. The Pharmacy located 23 of the 24 received bags of the drug, and that the 24th was the one from the ICU that potentially could have been given to the patient in error. The Pharmacy ultimately discovered that when the shipment of this drug was originally received, the bar code for the Wholesaler’s information was scanned from the box containing the drugs, but not that for the Manufacturer (both are on the shipments). The Wholesaler’s bar code was incorrect, listing the shipment as Magnesium Sulfate 2 grams, when indeed it was 4 grams. The Manufacturer’s bar code had the drug listed as the correct 4 grams. If the two bar codes had been scanned at the time of initial inventory, the discrepancy between the information on the two bar codes would have led this potentially impacting error to being discovered at the time of delivery, before the inaccurate drug made its way to our medication dispensing system.

A key to help understand how the error was missed is that the Pharmacy stopped carrying Magnesium 4gm bags quite awhile ago because of the concern that this type of error might occur. Instead, BIDMC orders several cases of Magnesium 2gm bags at a time. In this case, our wholesaler made a mistake when they filled our order and shipped one case of the wrong strength product along with several cases of the correct strength. The Pharmacy immediately changed their practice, and now both the Wholesaler’s and the Manufacturer’s bar code information are scanned together when received and inventoried by the department.

Lessons Learned

One essential lesson is simply this: when it comes to medication administration, the machine is not always right! Our automated medication dispensing machines are now organized so that they point clinicians to a single bin or cube where they should expect to find the medication as suggested by the computerized screen. Since the right medication is in the right place the majority of the time, we become less likely to check that what we remove is what we intended. Safe medication administration is still dependent on looking at the label on the actual dose.

Another essential lesson is that the near miss call–out is essential! Thanks to this call-out we were able to prevent the wrong dose of Magnesium Sulfate from getting to our other patients. The Nurse also took the important step of reporting this safety breach in our safety reporting system so that the event could be captured to help with trending of these types of issues.

In addition, our Pharmacy was able to rigorously look at their current practices to make an essential process improvement so the same type of situation and potential error does not happen again.


Ken Farbstein said...

Bravo for your call-out policy, and for your writing about this!

Automated dispensing machines can make it easy for multiple errors to occur. To read a case in point see Patient Safety Blog.

Note that the computerized system was also very quick in helping staff locate the other 23 bags before the wrong medication reached any patient.

e-Patient Dave said...


This is EXACTLY the kind of superb, competent process control I've been talking about, which we need to implement EVERYWHERE possible in healthcare.

If processes this comprehensive had been in place in March 2007 when I produced my vital post-nephrectomy urine specimen, the specimen probably wouldn't have gotten lost. Or at very least it would have been possible to track down at what point in the process it got lost.


The beautiful thing is that as this discipline settles in, people start thinking upstream and then farther upstream, about how such errors can be headed off before they even happen. That is SO disruptive (in a good way!), compared to trying to deal with the consequences later.

I haven't finished Christensen's new "Innovator's Prescription" but I hear that thinking is at the core of his prescription: transform outcomes and costs by preventing problems in the first place - including catching diseases at the very very earliest stages.

Okay, end Happy Rant. :–)

MedInformaticsMD said...

Note my comments on the general issues of barcoding, based on Koppel's paper on that topic, in a 2008 posting here.

-- SS

e-Patient Dave said...

Interesting 2008 post, Scot. I've got writing of my own to do tonight but I hope to look into the grid you wrote about. Very open to learning the differences between business computing and clinical computing.

Anonymous said...

This was a very good call and response by the hospital staff. However, it illustrates the incredible plethora of opportunities for error among the many entities involved in delivering health care, and the resulting necessity for expensive and time-consuming redundancies in error-avoidance procedures. Ultimately, one hopes for better automated systems in both the production side and delivery side that catch these errors, but even those can only go so far.

nonlocal MD

Paul Levy said...

Agree. We will always be dependent on every staff person to feel responsible for being alert to quality and safety lapses, and to believe it is part of the job to call out near-misses.

Barbara Olson, MS, RN, FISMP said...

My nurse's belief that a highly reliable bar-code/electronic e-mar system could be fallible saved me from a significant warfarin error. Wrote it up to honor nurses this week: http://florencedotcom.blogspot.com/2009/05/do-you-see-what-i-see.html. Thx for sharing another one!

Brenda RN said...

It is great that this near-miss error was caught before any patient was harmed. I agree with your emphasis on caregivers checking the medication label rather than relying on the medication delivery system. What is missing from your comments though is the importance of the pharmacy staff also reading the labels before they load the machine. If they had read the label, they would have seen that the bag contained 4mg not 2mg. I think technology and barcoding are essential. I rely on those barcodes when I remove meds from the Omnicell. But I always assumed that the person loading the medication checked to be sure that the barcode matched the actual medication. Computers don't think. They only give you what you put in. Shouldn't we make sure that what we put in is correct?