Tag Archives: medication error

Root Cause Analysis

Deadly medication error illustrates danger of discharge period

By ThinkReliability Staff

Medical errors can happen anywhere and at any time. However, these errors may be most likely to occur at transitions, especially the transition from the hospital to home when follow-up care is still required. Says Alicia Arbaje, an assistant professor at the Johns Hopkins School of Medicine, “Poor transitional care is a huge, huge issue for everybody, but especially for older people with complex needs. The most risky transition is from hospital to home with the additional need for home care services, and that’s the one we know the least about.”

The case of a woman’s death from medication errors during that transition period illustrates multiple errors that can occur during this period. We will capture the known details of this issue in a Cause Map, or root cause analysis. The first step in the Cause Mapping process is to capture the what, when, where and impacted goals in a Problem Outline. In this case, the patient passed away October 30, 2013, after discharge from a regional medical center in Missouri, where the patient was treated for congestive heart failure. Organizational goals that were impacted by the patient death (an impact to the patient safety goal), settlements with both the hospital and pharmacy (impacts to both organization’s legal/ financial goals), and the patient being administered a high dose of the wrong medication (an impact to the patient safety goal).

These impacts to the goals become “effects” of cause-and-effect relationships. The Cause Map contains all the cause-and-effect relationships that led to these impacted goals. Causes included in the map are verified with evidence, which can be provided by a variety of sources. Causes can be determined by asking “Why” questions, but more than one cause may be required to produce an effect. In this case, all necessary causes are included and joined with an “AND”.

The patient safety goal was impacted because of a patient’s death due to multiple organ failure when her bone marrow became unable to create blood cells as a result of an overdose of methotrexate. Methotrexate can damage blood cell counts and is primarily used to treat cancer and severe arthritis. The patient was administered a high dose (for methotrexate) of a drug that was not prescribed for her. When the patient left the hospital, the hospital phoned an order for a daily dose of the diuretic metolazone. However, according to court evidence, the order was written down by a pharmacy technician as a daily dose of methotrexate.

Because of the side effects of methotrexate, it is included in a list of eight “high-alert” medications that warrant special safeguards to prevent incorrect dispensing. The typical dose of methotrexate is much lower, usually only once or twice a week. Despite this, the pharmacist missed the error. In a testimony, he was unable to identify a specific reason for this oversight. The pharmacy manager said “there was a breakdown in the system.”

There were more opportunities for this error to be caught before this drug was dispensed to the patient. The patient herself could have noticed the incorrect medication based on the name or information on the enclosed information sheet. However, the patient likely did not fully understand the discharge instructions. Federal data shows that less than half of patients say they’re confident they understand discharge instructions. This patient was also receiving home health care, but neither of the two nurses that saw the patient identified the medication mix-up. Even though a primary purpose of home health care is to develop and follow-up on patient care, a 2013 government report found that more than a third of facilities did not do this properly. Medicare requires that home health agencies verify patient’s medications and check for possible interaction, but inspectors found that nearly a quarter of home health agencies inadequately reviewed or tracked medications for new patients. One of the challenges is that the typical providers of post-discharge patient care (nursing homes, rehabilitation facilities and home health care providers) did not receive any of the funding provided by Congress to upgrade to electronic medical records.

Several systemic issues were identified in this case and actions meant to improve these issues are still ongoing. One reason for increased use of electronic medical records is to avoid delivering prescriptions over the phone, which can result in transcription errors. Ensuring patients better understand their discharge instructions is another goal that could improve patient safety. Lastly, improvements to home health care agencies to ensure their required tasks are being completed effectively is clearly needed, but it has been difficult to determine the most effective way to do this.

To view the Cause Map of this incident, click on “Download PDF” above. Or, click here to read more.

Root Cause

Non-Sterile Product Administered Intravenously to At Least 40 Patients

By ThinkReliability Staff

A non-sterile product that was meant for clinical simulation (training) only was administered intravenously (via IV) to at least 40 patients, one of whom died and at least 17 of whom became seriously ill. Because the death was in a hospice patient, it was not determined definitively that it was caused by the solution. The Food and Drug Administration (FDA) is taking no chances – after the reports of patient injury, the FDA had released an alert warning medical practitioners not to use the product “for clinical simulation” on patients. The company that manufactured the products later implemented a recall.

Whether or not the patient death can be blamed solely on the IV use of a non-sterile product, administering a non-sterile product to a patient is clearly an impact to the patient safety and patient services goals. At least 17 injuries (which typically were discovered very quickly after use of the non-sterile IV product) have been tied to the error. The recall is a product goal to the manufacturer – which does not produce any sterile products. The investigation by the FDA is an impact to the labor goal. How these goals were impacted and what is being done or recommended to prevent these impacts can be captured in a Cause Map, a visual root cause analysis diagram of cause-and-effect relationships. (To view the Cause Map, please click on the image above.)

Patient safety was impacted because of the administration of a non-sterile IV product to patients. These patients were receiving saline product via IV to treat various medical conditions (dehydration, for example) and the product was not sterile. Because the product was for training purposes only, it was not meant to be sterile. Healthcare facilities that administered the solution said they were unaware that it was a non-sterile product.

The non-sterile product was delivered to the facility, whether by the ordering or delivery of the incorrect product. According to Dr. Alexander J. Kallen, the medical officer at the Centers for Disease Control and Prevention (CDC), “It seems like it’s not just one single mistake. There could have been instances where ordering was done by office staff who didn’t know the difference, as well as instances where the right product was ordered but they received the wrong stuff.” It does appear that the facilities in question (which are located in Florida, Georgia, Idaho, Louisiana, North Carolina, New York, and Colorado) all received the product from the same distributor, indicating a likely issue associated with the distributor’s delivery or ordering process. A nationwide shortage of sterile saline solution may have led to the use of additional suppliers, contributing to the confusion.

Even if the wrong product is delivered to a healthcare facility, there are still multiple opportunities to identify the problem before patient harm results. In this case, had anyone at the healthcare facility looked at the product – which was labeled “For clinical simulation”, the products could have been removed from the facility, as did happen at some facilities, which returned the non-sterile product.

The FDA has requested that all healthcare facilities and product distributors individually inspect saline product to be administered to patients to verify that it is sterile and not intended for training purposes. The manufacturer of the training products has asked its distributors to add language to its advertisements specifying that they are for training, and are not sterile for patient use. In the meantime, the FDA is working with manufacturers of sterile saline to increase the supply, and has provided links to available supply on their website.

What should you do? If you are involved in an IV transfusion, either as a patient or a practitioner, check what’s being delivered and ensure it matches your doctor’s order. Go to the FDA’s site to learn more about the recall, investigation or saline shortage.

 

Root Cause

Hospital Admits Fault, Implements Improvements after Death due to Medication Error

By ThinkReliability Staff

A hospital in Oregon administered the wrong medication to a patient who stopped breathing. Because of a fire alarm that happened shortly afterwards, the patient was not monitored for about twenty minutes. After that time the patient had experienced irreversible brain damage and was taken off life support on December 3, 2014.

In a surprising move, the hospital has taken responsibility for the error. Dr. Michel Boileau, the chief clinical officer, has stated, “We do know there was a medication error. We acknowledge that. It’s our mistake.” While an Oregon law, which took place in July, encourages transparency with patients and loved ones and reporting in the case of medical errors, the hospital says communication in the case of errors has been its practice for years and that it’s the right thing to do.

Supporting the transparency, the victim’s son says, “We want the community to know what happened. Precautions need to be taken. The only message we really have is that life is short and you never know when something like this could happen.”

Detailed information regarding the case has been released in the media. Using that information, it is possible to put together a Cause Map showing the cause-and-effect relationships that led to the death, and show how the hospital’s planned improvements address the causes.

In this case, administration of the paralyzing agent Rocuronium instead of the prescribed anti-seizure medication fosphenytoin caused the patient to stop breathing, leading to cardiac arrest and irreversible brain damage. Monitoring of the patient may have caught the lack of oxygen prior to irreversible damage, but in this case the patient was not monitored. Shortly after the administration of the IV, the hospital experienced a fire alarm (“code red”), at which point staff left the patient’s room and closed her door. Staff estimates she was unmonitored for about twenty minutes.

Medication errors that happen within hospital facilities almost always involve an error in the medication process. As part of the investigation, Dr. Boileau states, “We’re looking for any gaps or weaknesses in the process, or to see if there has been any human error involved.” So far the hospital has determined that the IV bag given to the patient was filled with the wrong medication at the in-patient pharmacy but then coded for the correct drug. It’s unclear exactly what happened at the pharmacy, but there was either no check of the medication filling or the check was ineffective, as it allowed the wrong drug to be delivered to the patient for administration.

According to the hospital’s chief nursing officer, Karen Reed, “We are all committed to honoring Ms. Macpherson’s name by learning everything there is to learn here and making sure no other patient has to go through this again.” While the investigation into the details continues, the hospital has already planned some improvements to work towards that goal.

To reduce the risk of medication errors, the hospital is designating a safe zone to be used for medication verification. (Distraction has been shown to be a primary driver of medication mix-ups.) They’re also reviewing and updating their medication protocols and ensuring that a detailed checking process is implemented. Because of the particular danger associated with mistakes involving paralyzing agents (like Rocuronium), alert stickers have been added to these types of drugs. Because of the issues with patient monitoring, procedures that ensure patient monitoring after IV administration (presumably even in the case of an unusual event or emergency) will be implemented.

What does this mean for you? Medication errors are considered rare, but even one is one too many. Medication administration processes at healthcare facilities must be designed to minimize the risk of error by reducing interruptions and ensure double checks. Other guides, such as alert stickers, can be used to emphasize particular risks (not limited to medication errors). In healthcare facilities (or any other facilities where operations can’t safely be put “on hold”), there needs to be a plan for ensuring that necessary tasks are performed, even with emergency or unusual situations.

Read more about this incident.

Learn more about medication errors.

Root Cause

Causes for Medication Errors Identified in Cumulative Cause Map

By ThinkReliability Staff

Despite continuing efforts to reduce patient safety impacts from medical errors, more work is needed to make patients safer. One of the areas which has been identified as a key safety issue is that of medication errors within healthcare facilities. A Cumulative Cause Map is a tool that can identify causes proactively (before incidents occur) based on industry experience, including past errors. As a Cause Map is a visual form of root cause analysis, a Cumulative Cause Map can be considered a visual form of Failure Modes and Effects Analysis (FMEA). It captures potential causes (causes that COULD result in an impact to patient safety) in order to develop and implement solutions that will reduce the risk of the impacts.

In this case, the term “medication error” is used to refer collectively to errors that result in patients receiving the wrong medication, patients receiving medication prescribed for another patient, patients receiving the wrong dose of the correct medication or having the correct medication delivered by the wrong route, and patients receiving medication to which they have a known allergy or has a negative interaction with another medication the patient is known to be taking. An adverse drug event (or ADE) results when the medication error causes patient harm. Our analysis will focus on preventable issues. (Patients may experience an ADE even when a medication is administered correctly.) About half of ADEs are considered preventable, i.e. they result from a medication error.

In this case, our Cumulative Cause Map will identify errors that occur at all steps of the medication delivery process. This process begins when a need for medication is identified and ends when the medication has been administered to the patient. At a very high level, there are four steps to this process: prescribing, transcribing, dispensing, and administration. The process typically begins with a physician, who prescribes the medication, moves to a clerk who transcribes the prescription (if necessary), then to a pharmacist who dispenses the medication, and then typically to a nurse, who administers the medication.

Based on information from studies, industry guides, and case studies of actual medication errors, common issues can be identified at each step of the process. In the prescribing stage, a medication can be prescribed for the wrong patient if there has been insufficient verification of the patient’s identity (and a matching of the patient to their medical records). Additionally, an inappropriate medication, dose or route may be prescribed if the physician is unaware of a patient’s allergies or other medications which could interact with those being prescribed. Miscalculating a dose is another potential error at the prescribing stage. Distraction and/or similar-sounding drug names are other causes for prescription errors.

In the transcribing stage, errors typically result from legibility issues on handwritten prescriptions. However, distraction and/or similar sounding drug names can result in the wrong medication/ dose and/or route of administration being transcribed. Distraction and/or similar sounding drug names is an issue during the prescribing step, as is miscalculating a dose. When medications have to be substituted (for availability or cost concerns), there’s also the potential to choose an inappropriate medication if a patient’s allergies or current medications are unknown.

At the administration step, medication can be administered to the wrong patient due to insufficient identity verification. Or, the wrong medication, dose or route can be administered due to similar sounding names and/or distraction. According to the Institute for Safe Medication Practices, every interruption increases the risk of medication error 12.7%, and medical staff can be interrupted as often as every two minutes while working on the medication delivery process. For this reason many hospitals are trying to reduce interruptions of medical staff during this process by various means.

By looking at the causes that come up again and again in the proactive analysis, steps for improvement at each level of the process can be identified. Ensuring that the right patient is matched to the medical record/ care instructions at every step of the process can reduce medication being administered to the wrong patient. The use of non-handwritten prescriptions and including both the drug’s brand name, generic name and purpose can also reduce the risk of the wrong drug being administered. Ensuring that drug allergies are clearly captured within a patient’s records (and potentially on the patients themselves, in the form of a wristband) and that a current medication list is up to date can reduce the risk of drug reactions. An organization’s experience with these different types of errors will allow it to determine what level of control over each cause is necessary to reduce the risk to an acceptable level.

To view the one-page PDF with a proactive analysis of medication errors in healthcare facilities, please click “Download PDF” above. To learn more about Medication Errors, please join our FREE Webinar on December 18th.

Root Cause

Wrong Dye Injected into Spine During Surgery

By Kim Smiley

In the high stress, fast paced operating room environment, high consequence errors can and do happen, but the risk can be reduced by analyzing medical errors and improving standard work processes.  A recent case where a woman died unexpectedly after a routine procedure to insert a pump underneath her skin to administer medication offers many potentially useful lessons.  The wrong dye was injected into her spine during the surgery, which is the type of error that should be entirely preventable.

A Cause Map, or visual root cause analysis, can be used to analyze this issue.  To build a Cause Map, all causes that contribute to the issue are visually laid out to show the cause-and-effect relationships.  The general idea is to ask “why” questions to determine ALL the causes (plural) that contributed to the problem, and not focus the investigation on a single root cause because this allows a wider range of solutions to be considered.

So why did the wrong dye get injected into the patient?  The dye was injected because it was used during the surgery to verify the location of tubing that was threaded into the patient’s spine and the wrong dye was used.  The surgeon needed the dye to verify the location because the tubing was inserted during the surgery and it was difficult to see. The tubing was part of a pump that was being stitched under the patient’s skin to administer medication directly to the spine to treat symptoms from a back injury.  The patient had broken several vertebrae during a fall.

And now on to the meatier part of the discussion in regard to medical error prevention – why was the wrong dye used? The request for medication (dye) was given orally by the doctor to the nurse who passed it along to the pharmacy so it is possible that the pharmacist missed that the dye was intended for use in the spine.  The exact point where the work process breakdown occurred wasn’t clear in the media reports, but it is known that there were several checks in the process that failed for this type of error to occur.

Following this incident, the hospital did make changes in their work process to help reduce the likelihood of a similar error occurring.  The hospital now uses detailed written orders for medications except in emergencies when that isn’t possible.  The written order includes information about how the medication will be administered, which would have clarified that the dye was intended for use in the spine in this case.

Root Cause

Failure to Read Back Physician Order Causes Patient Death

By ThinkReliability Staff

A patient suffering from pneumonia required a bedside bronchoscopy in a California hospital.  In order to provide sedation for the procedure, the physician performing the procedure requested a dose of Versed.  Although the actual dosage requested was not recorded, the nurse gave the patient 2 milligrams via IV and, a minute later, another 2 milligrams.  The maximum published dose for Versed is 1.5 milligrams over no less than 2 minutes.

Because of the bedside scenario and the verbal order for medication, the nurse was required by hospital policy to repeat back the order.  He did not, so there was no opportunity for the physician to realize the error.  Within a few minutes, the patient stopped breathing and was administered CPR.  However, the patient never regained consciousness and died nine days later.

We can look at this issue within a Cause Map, a visual root cause analysis that addresses all the cause-and-effect relationships that resulted in the issue being investigated.  The analysis begins with the impacted goals.  In this case, the patient safety goal is impacted due to the patient death.  The failure to follow hospital policy regarding repeat back of verbal orders is an impact to the compliance goal.  The patient services goal is impacted by the overdose that was administered.  The overdose resulted in extra care required for the patient, an impact to the labor goal.  As a result of the issue, the hospital was fined $50,000 by the California Department of Public Health.  (Click here to read the report, which was used to create this blog.)

Beginning with an impacted goal and asking “Why” questions adds more detail to the analysis.  In this case, the overdose occurred due to the need for Versed and the larger than ordered dose.  The larger than ordered dose resulted from a miscommunication between the physician, who ordered the Versed, and the nurse, who administered it.  The nurse did not repeat back the order as required, and the physician did not request a repeat back.  Although the requirement was apparently for the person receiving the order to repeat back, patient safety is everyone’s responsibility.  Pausing the procedure to ask for a repeat back would have likely saved the life of this patient.

Not mentioned in the analysis was the conditions under which the order and procedure were performed.  Clearly ability to hear was a concern.  A study published in May of 2013 determined that background noise in the operating room can result in difficulty in communication between team members, not only by affecting team members’ ability to hear each other, but could also impair an individual’s ability to process auditory information.  Other studies have found that other environmental factors can impact medical errors.  Specifically, one study found that most medication errors were more likely to occur when the previous 30 minutes were hectic and involved staff member distraction.  It is unclear how much of a role the environment played in this case.

The hospital involved in the issue focused efforts on ensuring hospital policies were re-emphasized.  While this is a typical response in this type of situation, the training efforts must ensure that the importance of the policies is emphasized, possibly by using lessons learned from actual cases to demonstrate the risk of these policies not being followed.  Additionally, all staff must take responsibility for patient safety.  Even though the policy required repeat back by the nurse, other staff members involved with the procedure should have played a role in ensuring that the communication between members was adequate to ensure patient protection.

Want to learn more? See our webpage about medication errors in medical facilities or watch the video.

 

Root Cause

Adult Dose of Heparin Delivered to Premature Infants

By ThinkReliability Staff

On September 16, 2006 6 premature newborns in Indianapolis were given adult doses of the blood thinner heparin, used to prevent blood clots that could clog intravenous (IV) tubes.  Adult doses are 1000x more concentrated than infant doses.  Three of the babies died and the other three were in critical condition.  In 2007, in Los Angeles, an overdose was given to three more babies due to the same error.  Luckily none of those babies died.  (Up to 17 babies in Texas also received heparin overdoses in 2008, but these were caused by a mixing error at the hospital pharmacy.)

We can examine this issue in a visual root cause analysis, or Cause Map.  Fully investigating the errors that occurred for these overdoses to happen can lead us to solutions to increase healthcare reliability by decreasing the risk of the same situation recurring.

We begin with the outline, where we capture the what, when and where of the incident, as well as the impact to the organization’s goals.  These medication overdoses impacted the patient safety goal because they resulted in fatalities and serious injury to the babies who received the medications.  Additionally, employees involved in the issue can be affected as a second victim.  Death or serious disability due to a medication error is a “Never Event“, which is an impact to the organization’s compliance goals.  Patient services are impacted due to the incorrect drug dose delivery.

Once we’ve determined the impacts to the goals, we can ask “Why” questions to determine the cause-and-effect relationships that led to the incident.  In this case, 5 opportunities for double-checking the dosage were missed.  The wrong dosage was missed as 1) the bottle was removed from the pharmacy, 2) the bottle was placed in the cabinet, 3) the bottle remained in the cabinet, 4) the bottle was taken from the cabinet, and 5) the drug was administered to the babies.  Some of the reasons that it was missed: there was no effective double check by another staff member, there was no check by a computer and of course due to human error, which was aided by the issue that the adult dosage bottle and the infant dosage bottle looked practically identical (this has since been remedied).

An article in The Journal of Pediatric Pharmacology and Therapeutics states, “As frequently occurs, all of these heparin-associated medication errors happened when a number of system failures occurred simultaneously. System failures included: 1) failure to carefully and accurately read the label on the medication vial prior to administering the drug to the patient; 2) inaccurate filling of automated drug-dispensing cabinets; 3) non-distinct “look-alike” labels on the heparin vials; 4) similar size of the heparin vials as both were 1-mL vials; and 5) “factor of ten” dosing errors.”

Many solutions to this type of error (such as requiring double checks by staff members and using a computerized prescription dispensation system) were suggested as a result of this and other heparin overdoses over the past several years and are already being implemented at hospitals across the nation.

To view the Outline, Cause Map and potential solutions please click “Download PDF” above.  Or click here to read more.

Root Cause Analysis

Study Finds that Diabetics are at Risk of Medication Errors

By Kim Smiley

A new study found that nearly a third of diabetic hospital patients experienced a medication error in a one week period.  The study examined bedside data for 12,800 patients and 6,600 patient questionnaires for hospitals in England and Wales.  Medication errors when treating diabetics can have severe consequences because many diabetics require medication to maintain healthy blood sugar levels.  Blood sugar levels that are either too high or too low can result in significant illness and even death if untreated.

The two most common errors found by the study were failing to properly adjust medication when a patient’s blood sugar level was high (23.9%) and failing to sign off on the patient’s bedside information chart when insulin was given (11.1%).

This issue can be examined by building a Cause Map, an intuitive, visual root cause analysis format.  The first step to building a Cause Map is to determine the impact to the overall organizational goals.  In this example, the risk to diabetic patients is an impact to the safety goal.  The next step is to ask “why” questions and add the cause boxes to the Cause Map to illustrate the cause and effect relationships between all the factors that contributed to the issue.

In this example, the risk to the diabetic patients occurred because medication errors occurred and the patients required medication to maintain healthy blood sugar levels.  The study did not provide details on why the medication errors were made by hospital staff, but that information could be added to the Cause Map if it becomes known.  A Cause Map can be still be useful when only a high level map can be built because it can help identify an at risk population and a common problem, the diabetic patients and the medication errors, which could help identify where more research is needed or where resources could be directed.  To view a high level Cause Map of this issue, click on “Download PDF” above.

A potential solution that has been suggested for this problem is to improve training for hospital staff on how to properly treat diabetic patients.  A more detailed look at understanding exactly why the staff is making errors could help direct the training plan to the most needed areas.

Root Cause Analysis

The Number of Accidental Child Poisoning from Medication is Increasing

By Kim Smiley

A recent study in The Journal of Pediatrics revealed that the number of accidental drug overdoses by children is increasing in the United States.  An investigation of hundreds of thousands of patient records showed that the number of accidental drug poisonings among children under 5 years of age increased 22% from 2001 to 2008.

In 95% of the cases, the overdose occurred because the child self-ingested the drugs, as opposed to a labeling or dosing error.

Why?  How are so many young children finding and consuming medication? And more importantly, what could be done to prevent these accidental overdoses?

This incident can be built into a Cause Map, an intuitive visual method for root cause analyses.  Better understanding the causes that contribute to a problem can lead to finding better solutions.

According to the study, one of the causes contributing to the increase in accidental overdoses is that there is simply more medication in homes with small children.  As lifestyles change, the population is facing more health problems.  Obesity and metabolic syndromes are more common at younger ages than in the past and more homes of small children now contain medication associated with these illnesses as well as a variety of other medications.

Changes in drug technology have also affected the severity of overdoses, if not the number of occurrences.  More sustained-release medications are being prescribed and they can result in more severe poisoning.

The study also suggests that there is a possibility that people are being less strict about storing drugs safely, but it’s difficult to prove.  There is also the issue that people may not be aware of how dangerous their prescription and OTC medications are.

One thing we know is that the current safety precautions are ineffective.  Children are findings ways to open child proof caps and warning labels aren’t sufficiently motivating adults to safely store medications in locked or inaccessible locations.

Changing medication packaging is one of the potential solutions being considered for this problem.  New packaging that would be more difficult to open or would only dispense limited amounts of medication.  Bottles can be designed to dispense one pill at a time or restrict the flow of liquid.

Never Event

Infant Death Due to Sodium Chloride Overdose

By ThinkReliability Staff

On October 15, 2010, a 40-day old prematurely born infant died from a sodium chloride overdose at an Illinois hospital.  Because a computerized system was involved, this case has been noted as a harbinger for possible issues resulting from the use of computerized systems.  To learn more about what happened, we can look at the case in a visual root cause analysis, or Cause Map, to examine all the causes.

First we begin with the impact to the goals.  The infant’s death was an impact to the patient safety goal.  A death resulting from a medication error is a “never event“, which is an impact to the compliance goals.  There is a related wrongful death lawsuit, which is an impact to the organization’s goals.  The overdose of sodium chloride delivered to the patient is an impact to the patient services goal.

We begin the analysis with the impacts to the goals and ask why questions to fill out the Cause Map.  The infant death was caused by the sodium chloride overdose, which occurred when the infant received more than 60 times the dosage ordered by the doctor intravenously.   The infant was receiving sodium chloride intravenously to provide nutrition, as he had been born prematurely.  Although a blood test indicated abnormally high levels of sodium, it has been reported that the lab technician assumed they were inaccurate, resulting in the infant not receiving immediate care for the overdose.

When a process – in this case, the medication delivery process – does not work correctly (such as occurs when an overdose is given), it means that the checks at every level of the process were ineffective.  The final check at the patient’s bedside was ineffective because the label on the IV bag did not match the actual contents.  It’s unclear how that occurred.  The error was made at the pharmacy, when a pharmacy technician entered an incorrect number into the compounding system.  Normally entering a too-high dose would trigger an alert with an automated system, but the alerts were turned off.  Part of the reason for the error was that the pharmacy technician had to manually enter the prescription in the first place.   A  doctor enters a prescription via the automated dispensing system.  However, the automated dispensing system, and the computerized compounding system did not communicate with each other, so for orders that required compounding, a technician had to transfer the order from one system to the other, manually.

A computerized system is no better if it’s not used properly.  If parts of the system don’t communicate with each other, and safety checks are turned of, a computerized system may actually be less safe, especially if people expect the automatic checks are being performed, and so don’t perform any of their own.  Computerized systems have a lot to offer – namely, reducing the number of medication errors relating to illegible handwriting or providing automatic checks for drug interactions.  But these systems are not fail-safe and checks used to ensure that patients