Lessons learned from a fatal medication error:-- reflections for CRNA epidural order

[NRSKarenRN, BSN, RN]

From: Agency for Healthcare Research and Quality

Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

This article discusses how a hospital responded to a fatal medication error that occurred when a nurse mistakenly administered epidural pain medication intravenously to a pregnant teenager. Findings from the root cause analysis of the error revealed underlying factors including fatigue (the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented a bar coding system, but not all nurses were trained and workarounds were routine), and human factors engineering (bags containing antibiotics and pain medications were similar in appearance and could be accessed with the same type of catheter). A range of safety interventions were implemented as a result. However, the related editorials by leaders in the safety field (Drs. Sidney Dekker, Charles Denham, and Lucian Leape) take the hospital to task for focusing on narrow improvements rather than using complexity theory to solve underlying problems, and for creating a "second victim" by disciplining the nurse (who was fired and ultimately criminally prosecuted) rather than acknowledging the institution's responsibility and the caregiver's emotional distress.

The article and commentaries provide a fascinating, in-depth look at the true impact of a never event.

Full text: http://psnet.ahrq.gov/public/Smetzer-JCJQPS-2010-s4.pdf

Related editorials (PDF)

• Who’s to Blame? by Lucian Leape
  

There is a second tragedy at St. Mary’s Hospital that is

scarcely hinted at in the otherwise excellent report by

Smetzer et al. of the investigation and response to a terrible fatal

medication error.1 That tragedy is what happened to the nurse

who made the error, Julie Thao, whom the hospital blamed for

the mishap and fired. Not only was this action calamitous for

Julie, but if the hospital had taken institutional responsibility at

the outset, the criminal indictment and loss of licensure might

not have occurred. Julie was truly a second victim in more ways

than one....

,,Because, as the mantra since the Institute of Medicine

report To Err Is Human 2 insistently reminds us: Errors and

mishaps are caused by bad systems, not by bad people. Who is

responsible for the systems? The hospital. Individual frontline

caregivers—doctors and nurses—do not create or change systems,

the organization does.

[CRNA2007]

Why did the Nurse work a double shift? I bet it was her choice to work the double shift. she should have checked the medication before administering it. She shouldn't have bypassed the barcoding system. To say this nurse did not cause the death is inexcusable. So many BASIC things that everyone learns in nursing were not done. I don't anyone other than the nurse is to blame. She didn't follow the very basic 5 rights of medication administration. Whether or not the bags look like antibiotics is irrelevant. That's why you verify the medication upon administration.

[Pierrette]

Julie was truly a second victim in more ways than one....

Julie, the nurse, forgot Nursing 101:

1) Right Patient

2) Right Route

3) Right Dose

4) Right Time

5) Right Medication.

[OC_An Khe]

Excellent article and I recommend all RNs and those aspiring to to become Nurses read this article, particularly those involved in Quality Control and RCA.

Thanks Karen for posting this,

[Class2011]

Interesting article! Shame that after all that investigation and discovery, they still had a need to punish the nurse. It would've been much better to keep the nurse in the system and encourage her to tell the story to colleagues often.

Below are two concepts from human factors research discussed in the article. We will all do well to keep them in mind.

■ Faded perception of risk. The nurse had given many patients IV penicillin before the day of the event, and the familiarity of the drug allowed the perception of risk to fade while she prepared the medication for administration. In fact, the risk of making a mistake with the more "routine" medications such as penicillin was higher, given that much more conscious double-checking tended to occur when administering less typical medications. Familiarity with the intended product reduced the attention given to reading the label.

■ Inattentional blindness. When someone performing a task fails to see what should have been plainly visible--in this case, a pink warning sticker--and he or she cannot explain why it happened, the cause is usually rooted in inattention blindness, a condition that all people exhibit periodically. 1 When reading a label, most of the visual processing occurs outside of conscious awareness. Far more information than can be processed is visualized. 2 To combat information overload, the brain scans and sweeps until something sticks out to capture its attention. Unfortunately, the brain is a master at filling in gaps and making do, compiling a cohesive portrait of reality based on just a flickering view. 1 In this case, we presume that the orange color of the pharmacy label captured the nurse's attention and that anything lying outside the initial capture of attention--such as the actual drug name on the label and the pink warning label--got short shrift. How the brain sees the world and how often it fumbles the job is further influenced by distractions and fatigue.

[tewdles, RN]

excellent...thanks for the links...

[Class2011]

Why are nurses the quickest of all to hang their colleagues out to dry? Do people really think she deserved Criminal Prosecution?

Read up on Root Cause Analysis and you will almost always find a series of unfortunate events occurring at just the right time, and in just the right sequence to allow the error to transpire. Nurses are, of course, the last line of defense for the patient. But averting any one of those events can prevent the error from reaching the patient.

As the article points out, it has long been known that one of the simplest ways to prevent this type of error would be to have IV tubing, bags, and ports incompatible with epidural tubing, bags and ports. This is analogous to how anesthesia gases are loaded with the keyed system. Without that safety mechanism, I am sure that we would see wrong gas errors--and probably by some of the most experienced providers.

I know it's always fun to have someone to blame, but honestly, there but for the grace of god ... I pray the same for you.

[wtbcrna, MSN, DNP, CRNA]

Look alike medication containers are a real problem. Where I work now the droperidol and zofran containers look almost exactly alike, and also the ephedrine ampules and dilaudid ampules are also almost identical.

I didn't see in the article, but I wonder if they tried intralipids to treat the patient. Intralipids are about the only thing that has been proven to help with local anesthetic toxicity. Wolters Kluwer Health

[RedCell]

Bad situation, at least the midwives with knives got the baby out and the nurse didn't slot the entire family. I wonder if this institution had access to intralipids. Might have been able to free up some of those sodium channels to get a bit of cardiac depolarization going.

[excited1]

Reading these articles and responses are such helpful reminders to ALWAYS follow procedures. They are there for a reason! Thanks for the post.

[stanman1968]

This story illistrates several points, the one I would like to emphisize is that while there may be systems in place to prevent stupid errors but the ultimate protection is a CAREFUL AWARE CLINICAN. Everything else is window dressing really.

This nurse deserves to loose her position from my understanding she bypassed several points of saftey and failed to perform basic rights.

My sympathy is for the victims, and that is not the nurse.

[Class2011]

I have plenty of sympathy to go around, but it's neither here nor there. I'm more interested in learning how to prevent and avoid errors. Targeting an individual like this just let's all us other human's off the hook and takes the institutions off the hook as well. It does nothing to prevent it from happening again. I still say pharmacy should be putting bupivicaine in bags that are incompatible with IV tubing

Here's another concept from the article worth considering called Hindsight Bias

The tendency to believe, after learning of an outcome and why it happened, that one could have foreseen it and prevented it; the tendency to oversimplify and misrepresent the conditions that led to an error once the outcome is clear and the correct pathways/decisions that would have improved the outcome are known

As becca wrote, the article is a reminder to follow protocols as they are there for a reason. Yet, this nurse was sited for not following bar-code protocols that were just introduced at the hospital. Did you see all the problems the audit showed with the system--including a lousy 50% unit-wide compliance with the protocol. (The whole thing sounded just like how the implementation went down at my hospital. Nurses used all kinds of work arounds because medications wouldn't scan or weren't ordered right for the scanner to accept.) Any protocol that is getting only 50% compliance is clearly not ready for prime time and it's no basis for holding an individual accountable.