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.