Near Misses, Close Calls, etc.

[Jamuhh]

I am starting a project at work to help improve reporting of near miss events.

I am trying to gather real-life examples of near misses. If you look through the interwebz, near miss is defined as an event that didn't reach the patient but could have had terrible consequences. I would also like to hear about events that reached the patient but didn't cause harm (you might call this risky behavior instead.)

I know it's hard to put yourself on the line and admit when you've had a near miss, so I'll give some examples of my own.

--

*ibuprofen was prescribed and approved by pharmacy for a patient under 6 months (none was ever given to the patient)

*I wasted the wrong amount of a drug (didn't waste enough) but caught the mistake before administering

*I gave a med via PICC line w/o first flushing the previously running med; the two drugs were compatible but I was unaware of this and could have caused harm if they were not. (More of a risky or reckless behavior).

*We have pt cubbies for meds; both current and d/c'd patient prescribed the same nasal saline. The current pt dose had not arrived and d/c'd patient's dose was still in cubbie. I grabbed saline without looking at label and once in the room scanned the barcode to see that it did not belong to that patient. (Sure, it's just saline... but could have been something else.)

*I've taken CHG wipes to patient who is allergic as well as non-verbal but realized the mistake just before starting the wipe down

*The wrong weight was charted on a patient at admission. The physician prescribed a medication based on this incorrect weight, but the pharmacist reacted with There's no way a 14 year old kid weighs 5kg. Fix this weight!” (Imagine if the weight was more likely to be correct but was off significantly!)

--

Thanks y'all! Let's get a dialogue going!

[cayenne06, MSN, CNM]

Came thisclose to using providing iodine on a patient for a straight catch prep...who had a documented anaphylactic shellfish allergy.

this didn't happen to me, but the other day one of my NP colleagues prescribed a medicine to a patient that was very closely related to a med that she had had a documented severe reaction to. Script was written on paper, and the error wasn't noticed till the patient had already left. Her phone number was not in service! Luckily we contacted her via her emergency contact, and we also called the pharmacy she had on file to notify them in case the patient happened to have it filled there. Very stressful, and a good reminder to double check these things in real time.

[RainMom]

About once a month over the past several months in pacu or on the floor, I have found or heard of incidents where a pt is given a DNR band when there is NO order or documentation in the chart. It appears that at some point a nurse is taking a pt's word that they are DNR when they in fact only have a living will. We did once find a pt who WAS a DNR who did not have a band or order, but the prior record included the documentation.

Ugghh! So frustrating...One of these days someone will code & the wrong actions (or inactions!) will be taken based off this huge error.

[Jamuhh]

Good catch, and thanks for contributing! Interestingly, I read this a few weeks ago about shellfish/iodine. I think that needs to be studied more.

Iodine Allergy

[Jamuhh]

Wow, that one is huge. We almost never have to worry about that in peds, but definitely would be a problem in adult world.

Does your hospital have a reporting system?

[RainMom]

Wow, that one is huge. We almost never have to worry about that in peds, but definitely would be a problem in adult world.

Does your hospital have a reporting system?

Yeah, I've written incident reports over the ones I've caught personally & there have been some mass emails for re-education to nursing staff. I had never come across this before but we have been hiring a lot over the past several months & I'm just kind of wondering if perhaps some of the new nurses are the ones making this mistake over & over.

The last one I caught was a pt, POD 2 after an elective surgery, that was to be discharged. I have no idea at what point that band went on the pt, but it's scary to think about what might have happened if she had coded at some point during her stay.

[CountryMomma, ASN, RN]

IV KCl replacement ordered for pt with a PIV, no CVC. Warning label on the bag indicating that it was a CVC-ONLY infusion concentration was conspicuously missing. I had spiked and primed the tubing, hooked up to the pump, changed the drug library, and scanned the med just before hitting start. Noticed an administration warning on the MAR that the drug came in 2 strengths depending on route of administration. Sure as excrement, this pt had been sent up a CVC dose instead of the PIV diluted bag. I took everything back down, sent it back to pharmacy for review, filed a safety report/event report, notified the physician of the near miss, and then slunk off to the bathroom to shake and gag a little. Imagine a KCl burn to the PIV...poor pt!

I struggled for a while afterwards with the heavy knowledge that despite the fact that I have the least amount of education, I'm am the LAST stop between bad meds and the pt.

[Jamuhh]

Great save, CountryMomma! It wasn't the "right dose" :)

[klone, MSN, RN]

I had a near miss that scared me pretty badly. I was asked by a provider to give Rocephin to a patient (I work in a clinic setting). I got it all prepared, went into the patient room, asked for two patient identifiers and if she had any allergies. She mentioned that she's allergic to cillins and "-caine" meds. I reassured her that the medication I was about to give is not related to penicillin.

I cleaned off her skin, and just as I was about to dart the needle in, she said "Is the medication going to burn?" and I responded "A little, but we mix it with Lidocaine to help prevent that." It was weird, because it was like I was outside myself, hearing what I was saying, and both the patient and I realized at the same time that I was about 1/2 a second away from injecting her with a substance that would cause an anaphylactic reaction (I learned). I think I may have actually said "Oh, sh*t!" as I pulled my arm away.

I apologized profusely to the patient. She was very sweet about it.

[Jamuhh]

Amazing catch, klone! May borrow this one as an example :)

[applesxoranges, BSN, RN]

So one day I had a confused patient that no one wanted to see. Eventually on coming super doc came in and another nurse pulled him into a room because no one was coming to help me out by giving us meds to calm this patient that is sideways or facing the wrong way in bed.

He gave some verbal orders and then gave us more verbal orders if it didn't work. Resident was in the room too. It was something along the lines of haldol, then given haldol, ativan, cogentin. Attending left and resident was repeating orders and she said geodon. I said I thought provider said cogentin.

Resident said "oh, it's the same thing."

Me: (um? I don't think so. You did go to school longer but pretty sure they aren't).

So then I am second guessing myself and I double check with two nurses after seeing the order for geodon instead of cogentin (she put the other two in correctly). I pull cogentin and go to her.

Me: Are you really, really, really sure you meant geodon instead of cogentin? (Attending over hears me asking this)

Resident: Yes

Provider then explains the reason why he ordered the haldol/cogentin combo to her. She then says she thought he said geodon. My eyes were huge when she said that.

Old hospital:

Paramedic did the triage and she did not enter the shellfish allergy. I was starting an IV and heard him say the shellfish allergy. So when CT for PE was ordered, I had to tell the provider we can't do that.

[mago8388]

How can a resident confuse Cogentin with Geodon? Maybe with Neurontin that sounds alike but Geodon and Cogentin don't even sound alike. I do have a patient that takes Geodon and Neurontin together btw