Archive for the ‘adverse events’ Category

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 for more info about the apology

TBT: Ahrq 2014 safety culture survey.

In adverse events, culture on April 3, 2014 at 10:03 am

I called this throw back thursday because it doesn’t seem we have made much progress over the years. This is concerning. And probably relates to HAI and other undesirable outcomes. Maybe it’s just a fantasy that if we fix these the other things will fall into place easier? see my same post in 2012!

Areas With Potential for Improvement for Most Hospitals

The three areas that showed potential for improvement, or with the lowest average percent positive responses, were:

Nonpunitive Response to Error (44 percent positive response)—the extent to which staff feel that their mistakes and event reports are not held against them and that mistakes are not kept in their personnel file.
Handoffs and Transitions (47 percent positive response)—the extent to which important patient care information is transferred across hospital units and during shift changes.
Staffing (55 percent positive response)—the extent to which there are enough staff to handle the workload and work hours are appropriate to provide the best care for patients.

Infection kills 29 year old mom after childbirth

In adverse events on November 2, 2013 at 11:53 am

It is horrible that in today’s day and age, in the US, a mother dies after childbirth from necrotizing fasciitis. It’s even more horrible that hospitals let people suffer unnecessarily. All of the patient safety literature advocates apology, disclosure and compensation after a preventable event yet instead of doing this we leave families to deal with the death of their loved one and also the trauma of carrying on…worrying about daily life, providing for children, looking for answers..

While CMS makes never events that they wont pay for, this doesnt impact patients directly. Before never events there should have been the demanding of a fulldisclosure and fair compensation policy.
Not only is this the right thing to do, it directly forces hosptials to “pay up” so to speak which would make it likely that hospitals would truly invest in safety if for no other reason than the bottom line of expenditures..EMMC is a good hospital by many standards..but it cannot allow people to suffer any more than they have too when a mistake or preventable event occurs. Don’t listen to your lawyers, listen to your hearts and consciences…Pay up, involve the families in the investigation, be transparent and never let this happen again…and take care of the staff invovled as they are the second victims of this tragedy..dont let efficiency and productivity cause people to drift into unsafe conditions.

“They killed my patient then tried to hide it!”

In adverse events, human error on September 22, 2013 at 5:54 am

Scroll down to read a Blog post from a Boston area MD. I think somehow hospital administrators/boards justify this type of behavior in the name of the greater good (eg. keeping hospitals open and people in awe of their ability to heal..see Placebo). I think many healthcare workers have had their stories “changed” during investigations in which a hospital might have liability and have certainly been told things by lawyers that are less than the truth. Been there.

Let’s remember, the anesthesiologists involved doubtfully went to work that day planning to kill a pregnant woman! I wish the Md in this post (and the hospital) had been a little more understanding about human error. An admission of error followed by apology, full disclosure and just compensation by the hospital could have spared the family the trauma of a lawsuit and prevented the author of the following blog post from harboring angry feelings so many years later.

Scarier than Halloween: new estimates of harm

In adverse events on September 21, 2013 at 2:37 pm


Journal of Patient SAfety: A_New,_Evidence_based_Estimate_of_Patient_Harms

Objectives: Based on 1984 data developed from reviews of medical records of patients treated in New York hospitals, the Institute of Medicine estimated that up to 98,000 Americans die each year from medical errors. The basis of this estimate is nearly 3 decades old; herein, an updated estimate is developed from modern studies published from 2008 to 2011.

Methods: A literature review identified 4 limited studies that used primarily the Global Trigger Tool to flag specific evidence in medical records, such as medication stop orders or abnormal laboratory results, which point to an adverse event that may have harmed a patient. Ultimately, a physician must concur on the findings of an adverse event and then classify the severity of patient harm.

Results: Using a weighted average of the 4 studies, a lower limit of 210,000 deaths per year was associated with preventable harm in hospitals. Given limitations in the search capability of the Global Trigger Tool and the incompleteness of medical records on which the Tool depends, the true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year. Serious harm seems to be 10- to 20-fold more common than lethal harm.

Conclusions: The epidemic of patient harm in hospitals must be taken more seriously if it is to be curtailed. Fully engaging patients and their advocates during hospital care, systematically seeking the patients’ voice in identifying harms, transparent accountability for harm, and intentional correction of root causes of harm will be necessary to accomplish this goal.

No med is safe…

In adverse events on February 14, 2013 at 6:14 pm

As a society i think if we want to improve safety we really have to decrease our dependence on medications.

From fox news: “Samantha was 7 when she was given Motrin brand ibuprofen, family attorney  Brad Henry said. She suffered a rare side effect known as toxic epidermal  necrolysis and lost 90 percent of her skin and was blinded, he said.

She suffered brain damage that “thankfully” involved only short-term memory  loss, he said, and surgeons had to drill through her skull to relieve some  pressure.

The disease also seared Samantha’s respiratory system, and she now has just  20 percent lung capacity, Henry said.

The family filed the lawsuit in January 2007, claiming that Samantha was  blinded by Motrin and alleging that Johnson & Johnson failed to warn  consumers that the drug could cause life-threatening reactions. The five-week  trial ended on Wednesday when the jury awarded $50 million in compensatory  damages to Samantha and $6.5 million to each of her parents.”

Read more:

Fox says they know of 20 other children this has affected 😦

Find the mistake

In adverse events, human error, Human Factors, Root cause analysis on February 2, 2013 at 5:56 pm


This mini human factors test is going around Facebook.
Once you find the mistake it becomes almost impossible not to see it.

This illustrates two concepts
1) we see what we expect to see and our brain “corrects” what does not conform and therefore we can easily misread labels
2) Only hindsght is 20/20. When investigating an error after the fact, hindsight bias may cause one to think the error was foolish and was easy to detect at the time. Now that you see the error in this little picture it seems to be so evident that you wonder how it could have been missed initially

This is why we need barcode medication identification systems for preparation and administration.
And this is why it is so important to understand what was actually known at the time of an error and not what we know in hindsight. Many errors occur when people are doing what they always have done. Usually there is no significiant deviation from norm.

Transparent Health

In adverse events, culture, Human Factors on June 23, 2012 at 3:20 pm

Excellent patient safety resources from the folks at University of Illinois at Chicago.
Their blog:
There is a great post about collusion. If you see safety issues in healthcare and do not report, you should feel culpability.

Their educational site

If you are a healthcareworker, spend the $75 and Watch the Lewis Blackman story. You will be motivated to become a patient safety advocate. Lewis who was a totally healthy 15 year old, went in for elective surgery and died from a GI bleed related to toradol post op. The sequence of events happen everyday…there is nothing earthshattering until..there is.
Some key topics in this film: premature closure, confirmation bias, rapid response teams, chain of command, identification of rank of healthcare workers…listening to parents concerns..
Click to purchase pay-per-view From tears to transparency

I’ve spent precious time struggling to understand how my diagnosis was missed

In adverse events, Patient Safety on May 12, 2012 at 11:59 am

I have not been to this site for awhile but when I went there today it touched me as usual. I thought it deserved a post
These are some heartbreaking patient stories that help us see how much the transformation of heathcare is needed.
Some quotes:
“I’ve spent precious time struggling to understand how my diagnosis was missed. I’ve struggled with the knowledge that the delay in diagnosis resulted in a delay in treatment, which could have alleviated so many years of intense suffering, and potentially added many more years to my life (especially had I known to stop taking HRT).”
“At some point, Paul’s psychiatrist explained that his diabetes probably resulted from taking Seroquel. Paul wondered why doctors would prescribe him a drug that caused another illness, but he figured at first that they knew what they were doing.”

Realtime adverse event information

In adverse events, Patient Safety on April 24, 2012 at 7:55 pm

Here is a sample of the information at your fingertips on Adverse

FDA warns Fentanyl patch poses risk to children. 

On April 18, 2012, the FDA issued a safety alert to warn about the dangers posed to children from the accidental exposure to fentanyl. Health officials reminded patients, caregivers, and health care professionals of the importance of appropriate storage, use, application, and disposal of fentanyl patches.

Fentanyl is an opioid analgesic used for the treatment of breakthrough pain. Fentanyl patches are applied to the skin and treat patients in constant pain by releasing the medicine over the course of three days.

The FDA evaluated a series of 26 cases of pediatric accidental exposures to fentanyl patches reported since 1997. Sixteen of these cases involved children two years old or younger. Of these 26 cases, 10 resulted in death and 12 in hospitalization.

The FDA safety alert states:

Young children are at particular risk of accidental exposure to fentanyl patches.  Their  mobility and curiosity provide opportunities for them to find lost patches, take improperly discarded patches from the trash, or find improperly stored patches, all of which may result in patches being placed in their mouths or sticking to their skin.

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