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Can You Prevent This Medical Error?

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This article presents a case study published in the Annals of Internal Medicine in 2002. An older patient was much improved after a difficult postoperative course. On the morning of her planned transfer out of the ICU, she had a grand mal seizure and died as a result of medical error. I will lead you through the case step-by-step. See if you can prevent this error from happening again. You are reading page 2 of Can You Prevent This Medical Error?. If you want to start from the beginning Go to First Page.

Long time reader, first time poster.

This one struck a chord with me as I almost made this exact mistake. Order for 5000 units/1ml heparin subQ q8hr. Our heparin is dispensed in individual vials. Though individual patient meds are pulled and stored in individual drawers on our wow's. It is (was) not uncommon to find a vial of humalog or humalin sitting on top of the wow as these are 'multi draw' vials. I had scanned this patient, scanned the heparin and set it on the wow. You can see where this is going. I was talking to the patient and answering questions from her grown daughter as I drew up 1 ml of lispro into a TB syringe!

Fortunately I routinely stop just prior to giving meds to the patient to recheck everything. When I looked at the heparin vial and noticed the orange cap still intact, my stomach dropped, as I realized what I had done.

Somehow I remained composed with the patient, walked over to the sharps and dropped that 100 units of lispro in and started over. As I left the room, visibly shaking at what could have happened, I count my blessings that my Fundamentals teacher drilled us with the 5 rights over and over and over again. Thank you Ms Jackson!

I shared the incident with my manager, wrote up a 'near miss' incident report, and continue to share this story with other nurses on my unit , especially new nurses. You will never see a vial of insulin (or anything!) sitting on my wow unless I am preparing that dose. When I see a vial on someone else's wow, I will secure it. Overstepping? Maybe. But we wouldn't leave an oxy laying around, and a vial of insulin could do a lot more damage.

Slow down, pay attention and check, recheck, and check again.

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Obviously a large amount of blame rests with the nurse. And some of it may have to do with the nurse being overworked. However, I think we would miss an opportunity to prevent similar errors in the future if we just say that it was 2/2 an overworked nurse.

Why was the line being flushed with heparin? Not that 2002 (or earlier) was the dark ages, but this incident may have helped to lead to the idea that a flush with NS is sufficient to keep the line patent. If heparin is being used, why does the nurse have to draw it up rather than having prefilled syringes? Why does the heparin vial look so much like the insulin vial? The article address these and other causes that lead to the error, and I think we do a great disservice if we just write this up to an overworked nurse.

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Why was the line being flushed with heparin? Not that 2002 (or earlier) was the dark ages, but this incident may have helped to lead to the idea that a flush with NS is sufficient to keep the line patent.

We weren't flushing a-lines with Heparin even in the 80's.

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Good article and a very necessary reminder of why it is so important not to cut corners using the "Five Rights." I remember my nursing instructors from over 20 years ago telling us that when medication mistakes are made by nurses it's usually because of nurses not following the "Five Rights" for three checks, and that we should never take short-cuts with medication administration, and this has been true in my experience.

To give medications safely it's also necessary to know the patient's allergies, the indications for the patient getting the medication, the action of the medication, the expected effects, normal side effects, adverse effects and action to take, drug interactions, contraindications to receiving the medication, monitoring necessary after administration, assessment necessary prior to giving specific medications such as LOC, BP, heart rate, cardiac rhythm, respiratory rate/depth, electrolytes, other relevant lab values, kidney function, urine output, etc., and to know any other information about administering the medication that is necessary for patient safety.

Edited by Susie2310

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Checklist is great if someone has one stable patient all night to thus take 35 minutes per medication.

It's good for a student to get good habits, too, I guess. Then become more efficient later.

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Long time reader, first time poster.

This one struck a chord with me as I almost made this exact mistake. Order for 5000 units/1ml heparin subQ q8hr. Our heparin is dispensed in individual vials. Though individual patient meds are pulled and stored in individual drawers on our wow's. It is (was) not uncommon to find a vial of humalog or humalin sitting on top of the wow as these are 'multi draw' vials. I had scanned this patient, scanned the heparin and set it on the wow. You can see where this is going. I was talking to the patient and answering questions from her grown daughter as I drew up 1 ml of lispro into a TB syringe!

Fortunately I routinely stop just prior to giving meds to the patient to recheck everything. When I looked at the heparin vial and noticed the orange cap still intact, my stomach dropped, as I realized what I had done.

Somehow I remained composed with the patient, walked over to the sharps and dropped that 100 units of lispro in and started over. As I left the room, visibly shaking at what could have happened, I count my blessings that my Fundamentals teacher drilled us with the 5 rights over and over and over again. Thank you Ms Jackson!

I shared the incident with my manager, wrote up a 'near miss' incident report, and continue to share this story with other nurses on my unit , especially new nurses. You will never see a vial of insulin (or anything!) sitting on my wow unless I am preparing that dose. When I see a vial on someone else's wow, I will secure it. Overstepping? Maybe. But we wouldn't leave an oxy laying around, and a vial of insulin could do a lot more damage.

Slow down, pay attention and check, recheck, and check again.

Thank you so much for sharing this and taking steps to prevent it from happening again!

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In the old days art line flush bags had heparin in them but that fell out of favor several years ago. I have only flushed art lines with the bag of saline hanging.

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I'd like to know what kinds of errors are killing hundreds of thousands of people. Are we talking blatant administration errors? I imagine a huge factor would be polypharmacy among the elderly population - drug interactions, inappropriate doses ordered, allergies/reactions etc. I wonder what percentage is actual nurse-given, wrong med/dose etc.

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I think it is always a good idea to do a f/u on any death etc. but agree with Been there, done that that sometimes mistakes will be made because of the nurse being overworked or constantly interrupted during medication admin. I would like to see hospital admin and nurse orgs do something about that.

Also, I am a little confused about your clinical med admin check sheet, you do a head to toe, and VS prior to medication admin as part of your med pass and check the 5 rights 3X? Sometimes all these extra steps are what causes a nurse to feel pressed for time which leads to mistakes.

I agree - but this is the check-off sheet that is used for seniors - it isn't up to me to make changes - I am showing you what I was given. Someday maybe I will be faculty and can advocate for check-offs that are based more on real world nursing.

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Yes, of course it is preventable. "the nurse flushed the patient arterial line with insulin instead of heparin. "

You can quote all the studies you want, develop all the algorithms you want. The bottom line/ root cause is the nurse grabbed the wrong vial of medication. Most likely because they were overworked. The vials are similar in size and are available without a pharmacy check.

Heparin and insulin are high alert meds. The nurse that administered it, did not have another nurse check the administration of the high alert med.

I appreciate your comments, and I am wondering how just blaming the nurse prevents the problem from happening again?

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I've never heard of flushing an art line with heparin. Is that a standard practice?

It used to be, the article was published in 2002.

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It's these sorts of errors where we often seem to miss the forest for the trees. The problem isn't the safest way to store, draw up, and administer a heparin flush in a transduced arterial line, the problem is that there is no reason for flushing these lines with heparin in the first place. There is no benefit in terms of patency, and no reason to believe there would benefit since heparin is not a thrombolytic, and once it's been instilled into the line as a flush it will quickly be pushed through by the continuous flow of fluid from the pressure bag through the transducer.

The best solution to this scenario is to stop figuring out safest way to do something that even when done correctly has no benefit and only poses the potential for harm, and just don't do it at all.

SO true - this happened back in 2002, and best practice has certainly changed a lot since then!

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