Even with over 1.4 million events in the CHPSO database, fewer than 50 relate to concentrated insulin, underscoring the need for broad collaboration to understand the issues behind this high-risk medication. In February 2017, CHPSO started working with other PSOs and health care delivery systems to take a closer look at the types of incidents that are occurring and see what organizations are doing to prevent these types of incidents from occurring.
Case report: A patient with hemophilia was receiving both intravenous coagulation factors for his hemophilia and topical human recombinant thrombin (Recothrom) to treat surgical wound oozing. The nurse took both coagulation factor and Recothrom into the patient’s room. After being interrupted by other urgent care needs, the nurse picked up the Recothrom and administered it intravenously. The patient coded but was successfully resuscitated since the nurse quickly recognized and openly acknowledged his error, enabling the code team to provide appropriate timely treatment.
CHPSO convened a safe table forum where members discussed peripheral intravenous infiltration and extravasations, or PIVIEs. Many useful materials were shared and available for the benefit of all CHPSO members.
Post appendectomy, the patient’s mother wrote down the discharge instructions for administering pain medication to her child. She had the right medication and right time, but the wrong dose. Three days later, the mother rushed her child to the emergency department for constipation and shortness of breath. The child survived.
Some patients benefit from vancomycin blood level monitoring. The need to synchronize the blood test with drug administration adds steps to an already-complex medication process, requires interdepartmental coordination (nursing, pharmacy and phlebotomy) and multiplies the likelihood of problems compared to routine antibiotic administration. Indeed, review of CHPSO’s event reports database shows recurring errors with vancomycin monitoring.
If multi-dose vials must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters the immediate patient treatment area, it should be dedicated to that patient only and discarded after use. Examples of the immediate patient treatment area include patient rooms or bays, and operating rooms.
Medication administration is one of the most error-prone processes in health care delivery. The “five rights” are regarded as a basic goal for safe medication administration: right patient, right medication, right time, right dose, and right route. Many errors, including lethal errors, still occur when practitioners firmly believe that they have verified the five rights before administering a medication. How can this happen?
CHPSO’s parent company, the Hospital Quality Institute (HQI), has reviewed literature; consolidated successful experiences within California hospitals; and created brief, to-the-point toolkits for use today.
While electronic health records (EHRs) are intended to improve patient care, some risks are increased over the old paper record. Charting On Wrong Patient In EHR (COWPIE) is one such risk. A recent study examining one component of that, Computerized Physician Order Entry (CPOE) has some interesting findings. And, as the authors state, increasing automation, while reducing the opportunities for human error, also reduces the opportunities for humans to identify an error and intervene.
This article has been excerpted from the September/October issue of Patient Safety and Quality Healthcare.
Medication mishaps are the most common errors in health care. In 2011, ECRI Institute PSO spearheaded a unique collaborative for health care organizations to learn from medication errors, which represent the most frequently reported events submitted to ECRI Institute PSO — comprising about 25 percent of all events.
Identifying and responding to recalls can be difficult. The California Board of Pharmacy produced a guidance document, Addressing Drug and Device Recalls in Hospitals, intended to assist hospitals in setting up systems and procedures to make the process more reliable.The board summarizes its guidance as follows:
Investigators evaluated checklists designed for an “independent double checking” process in which the second person, without referring to the first person’s work, decides upon a setting or dosage, then checks his/her conclusions with those of the first person. Checklists were evaluated in a simulator to identity components that were most effective in identifying chemotherapy administration errors.