Lessons Learned

Echoes of Past Disasters

Case 1: Two patients were to receive intrathecal methotrexate with fluoroscopic guidance, Patient A in the morning and Patient B in the afternoon. The pharmacist dispensed the two methotrexate doses and the syringe for Patient A was delivered to his ward that morning. However, the syringe was not delivered before Patient A was transported to radiology. When Patient A arrived in the radiology suite, the technician called over to pharmacy looking for Patient A’s medication. In the pharmacy, the tech saw a single syringe labeled for intrathecal use and delivered it to radiology.


Correct Knee, Wrong Implant

I showed the surgeon the implant boxes, who confirmed they were the correct ones. The boxes were then opened and handed to the scrub nurse. Shortly after the cement had set, the knee in question didn’t look right. It was a right implant in a left knee. Informed surgeon that the implant was wrong. Surgeon attempted to remove the femoral component and a small piece of the femoral condyle came away that was cemented to the femoral component. At this point, three other surgeons scrubbed to assist.


Endoscopes May Not Be as Clean as You Think


Investigators found that scratches, chips, and dents on reusable medical scopes frequently occur and are havens for blood, tissue, and bacteria. A new study suggests that damaged scopes are not amenable to proper cleaning methods, and some damage may be difficult to identify without enhanced inspection. Evidence of contamination via bacterial growth in culture may be delayed beyond 48 hours.

Lessons Learned

Recothrom: Error-prone packaging

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.

Lessons Learned

Rolling Stools

Stools are a common source of falls for patients, visitors and staff. These chairs are not meant for long-term seating and are primarily used by staff. However, when left unattended, patients or their visitors will seek the vacant seat to rest or relax if all others are occupied. According to the Agency for Healthcare Research and Quality (AHRQ), between 700,000 and 1,000,000 people in the nation fall in hospitals each year. Stool falls reported in the CHPSO database were all unassisted and often led to visits to the ED for fractures or lacerations.

Lessons Learned

Opioids’ Dangerous Sidekick: Benzodiazepines

Opioids were the most commonly mentioned drug class among the CHPSO database. Of all the medication incident reports submitted to CHPSO, opioids were mentioned in 62,157 reports. The second most common drug class was benzodiazepines and non-benzodiazepine hypnotics, with 23,508 reports. Although this is a large drop off from opioids, benzodiazepines/hypnotics should not be overlooked as a source of potential harm.


CHPSO Patient Safety Alert: Insulin and Influenza Vaccine Switched
50 Hospital Employees in Brazil Given Insulin Instead of Influenza Vaccine

On April 30, 2016, fifty employees at a Brazilian hospital received a dose of insulin instead of the influenza vaccine.

The vaccine and the insulin were stored in the same refrigerator, and were retrieved by a staff member who confused the two similar-looking vials. The staff member took the wrong box from the refrigerator.

Those who received the incorrect, influenza-portioned injection of insulin were hospitalized. No adverse events have been reported.

Always separate look-alike vials and clearly label. Differentiation is key.

Lessons Learned

Doctor Who?
Telephone order authentication challenges

Case: from a event reported to CHPSO

Dr. Smith hospitalized Mr. Jones, a diabetic with a right below-knee amputation, for treatment and assessment of continuing pain in the left leg. Two days later, Dr. Smith phoned the ward clerk with new orders for Jones. The clerk shared the orders with Jones’ nurse, who was puzzled by the orders: triple the current dose of morphine, ask Dr. Thomas to do a left below-knee amputation, and administer an enema. The nurse called back Dr. Smith to clarify. Dr. Smith denied ever giving such an order.


Hospital Hardware Hacking

On July 31 the FDA issued a safety alert encouraging health care facilities to stop using Hospira Symbiq pumps due to cybersecurity concerns. This is not the first alert concerning hospital equipment cybersecurity and certainly will not be the last. If a hospital must temporarily continue using Symbiq pumps until replacements are in place, the following temporary measures should be taken (FDA, 2015):


Patient Safety Alert: Equipment Failure During Surgery and Replacement Parts

Several reports in the CHPSO database have pointed to the inaccessibility of spare surgical parts or tools while a procedure is in progress. In several cases, unique screwdrivers or drill bits have broken, or unique-size screws went missing. In at least one instance, the incision had to be temporarily closed with an implant partially secured and the patient was scheduled for re-operation to complete the procedure another day.


Patient fall risk associated with bed-exit alarm reset time
October 30, 2013

Our partner, ECRI Institute, has issued a patient safety alert concerning bed-exit alarms. Some bed-exit alarms do not immediately reset after sounding. During the reset process, which may take several seconds, there may be no indication that the alarm is not activated. If a patient exits the bed during this reset interval, the alarm will not sound, increasing the likelihood of patient injury.


FDA Warns of Insulin Dose Errors with Medtronic Pump Tubing
July, 2013

The US Food and Drug Administration (FDA) recently issued a safety alert and Class I recall concerning the MiniMed Paradigm insulin pump from Medtronic.


CHPSO patient safety alert—Viaspan from Teva Pharmaceuticals
March 26, 2010

During a CDPH visit, a CHPSO member hospital identified a potential problem with the packaging and distribution of Viaspan®, from Teva Pharmaceuticals. The hospital is concerned that the product can be inadvertently given intravenously.

Viaspan, a solution for the flushing and cold storage of organs for transplantation, contains about 125 mEq/L potassium.


CHPSO patient safety alert—Baxter Colleague Infusion Pump recall
May 4, 2010

In the most recent patient safety newsletter, CHPSO wrote about the new FDA initiative on infusion pump safety. Now, The FDA has asked Baxter to recall and destroy all of its Colleague pumps. The Colleague line of pumps have been the subject of several recalls, but the FDA is not satisfied with Baxter’s plans to bring the pumps into compliance. Baxter is estimating that this will cost the company about $0.5B.As of today, used pumps are still for sale by some third-party distributors (and on eBay!)

Here is the FDA’s statement:



CHPSO patient safety alert—Enteral lines and luer misconnections
July 13, 2010

In the May edition of CHPSO Patient Safety News we discussed the risks posed by using the same connector for differing purposes, such as breathing gases, enteral feeding and neuraxial access. Two recent publications highlight the seriousness of misconnections involving enteral tubes.


CHPSO patient safety alert—Air mattress settings change after being unplugged
November 11, 2010

A CHPSO member hospital, in analyzing the causes of pressure ulcers in its patients, noted an issue with some air mattresses that may represent a contributing factor.

The Sizewise Pulsate™ low air loss mattress replacement system is currently being used at that hospital for patients at risk for pressure ulcers or with existing pressure ulcers. The manufacturer states that the mattress combines automatic pressure adjustment, a friction and shear reducing cover, and clinician-friendly controls to create an optimal support surface for wound care treatment and prevention.


CHPSO patient safety alert supplement—Air mattress settings change after being unplugged
November 18, 2010

This supplement to the original alert serves as a reminder to clinicians that they should always check and recalibrate air mattress settings to the patient’s settings when reconnecting. Mattresses, when unplugged, may revert to a default setting.Additionally, though not mentioned in the first alert, on occasion caregivers may use a mattress control unit for a new patient without remembering to change the settings that were used for the prior patient.


CHPSO patient safety alert—Large Alcohol Prep Pad, Swab and Swabsticks recall
January 6, 2011

Due to the broad scope of the recall, we felt it was important to distribute this alert. Note that the product may be labeled with the name of the distributor rather than the manufacturer (“Triad”).Other names used were: Cardinal Health, PSS Select, VersaPro, Boca/ Ultilet, Moore Medical, Walgreens, CVS and Conzellin.


CHPSO patient safety alert—Large Recall of Povidine Iodine Prep Pads
March 21, 2011

H & P Industries, Inc., a manufacturer of over-the-counter products, is voluntarily recalling all Povidine Iodine Prep Pads due to concerns of contamination with the pathogenic bacterium Elizabethkingia meningoseptica. Use of contaminated Povidine Prep Pads could lead to life-threatening infections, especially in at-risk populations, including neonates, immune suppressed patients and surgical patients. Treatment options are limited for Elizabethkingia meningoseptica infections.


CHPSO patient safety alert supplement—H&P Industries and Triad Shut Down
April 5, 2011

US Marshals raided H&P Industries, which makes alcohol wipes and other products distributed by Triad Group. This company was the source of several recent large-scale recalls and CHPSO Patient Safety Alerts. The manufacturer ceased production after yesterday’s raid. Below is a partial listing of the recalled items.