SafetyDog

Archive for December, 2014|Monthly archive page

When sorry isnt the hardest word

In adverse events, human error, Human Factors, Interuptions, Multitasking on December 14, 2014 at 8:49 am

On Monday afternoon, a tragic medication error occurred at St. Charles Bend that ultimately caused the death Wednesday of a 65-year-old patient. The St. Charles family is devastated by this situation and our thoughts and prayers go out to the patient’s family along with the caregivers who were directly involved in this case during this incredibly difficult time.

“As soon as the error was recognized, we met with the patient’s family to explain what had happened and apologized for the grave mistake. We are in the process of investigating the cause of the error and are working closely with our internal team to ensure that it will not happen again. We will be reporting the event to The Joint Commission and the Oregon Patient Safety Commission in the coming days. St. Charles has never experienced a medication error of this kind in its history.

On the surface St Charles did everything right by the family in this tragic medication error. They owned the mistake, did not blame it on individual practitioners and they apologized to the family. They go on to decribe the process by which a paralytic was dispensed instead of a seizure medication. they performed a root cause analysis and came out with an action plan. They appear committed to this action plan on every level of their organization and they seem sincere in their determination to prevent this from ever happening to another patient.

Since Ms. Macpherson’s death, we have taken several immediate steps to ensure that an error of this kind will not happen again in our facilities.
Issue 1: Incorrect drug chosen and placed into IV
Our Response: We are enforcing a “safety zone” where pharmacists and techs are working that is intended to eliminate distractions. Verification of medication can only be completed in these areas.
Issue 2: Verification of drug dispensed
Our Response: A detailed checking process has been standardized and implemented to bring heightened awareness to the pharmacy team. New alert stickers have been added to paralytic medications and we are training nursing staff to watch for these stickers.
Issue 3: Monitoring of patient after IV started
Our Response: Nursing leaders are currently evaluating patient care processes to ensure we are following best practices. On every unit, our nurses are being hyper-vigilant about how we administer any intravenous medications. We are conducting frequent check-ins with our patients and we are consulting with patient safety experts across the country to ensure we are adhering to best practices.

The words that scare me in their action plan are those like “safety zone” “heightened awareness” and “hyper-vigilant.”
While these are admirable and many errors are caught by caregivers because of these very things, this is like medicating for an illness to cover the symptoms instead of giving a patient the cure.
Instead of a safety zone, move the dangerous drugs to another area that can only be accessed and prepared into a bag of IVF with the assistance of barcode scanning.
Instead of heightened awareness and stickers, manufacturers should make special syringes and tubing for high risk medications so they cannot be given inadvertantly.
Instead of hyper vigilance, establish staffing patterns that ensure nurses can focus on one patient at a time instead of continually multitasking. Study “priority setting” and how leaders can support front line staff by spelling out how to manage busy shifts (eg. what are essential practices for safety and what are second tier priorities like patient experience. High profile initiatives can come across as if they are more important than safety).
Proactively observe the medication process and visit nursing units to get staff’s ideas on what might be the next be error. Your staff know.
The heightened awareness and hyper-vigilance are totally people based interventions. If another medication error is made, I fear the staff will be blamed for their failure to maintain these super-human standards.

Visit http://www.sorryworks.net/oregon-hospital-apologizes-for-fatal-medical-error-shares-details-cms-272 for more info about the apology

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