You might remember me blogging about the Indianapolis incident where three babies died after being mistakenly given an adult dose of heparin back in 2007. The same set of failure modes led to a non-fatal overdose of actor Dennis Quaid’s twin babies.
These episodes teach us a lot about failure modes in healthcare (it’s often multiple things that go wrong in succession) and the management response to these problems.
It seems that hospital leaders often blame individuals for what appear to be systemic problems.
Some instances I’ve blogged about before:
- A Wisconsin nurse jailed for a medication error
- An Ohio pharmacist jailed for an error that occurred in his department
- A New York lab that fired “the technician responsible” for an error
I was at a hospital recently where we were talking about the Indianapolis case and I found an article that had a detail I didn’t remember from that episode:
The article, included some early reporting onthe errors that killed the babies, including:
Early Saturday morning, a pharmacy technician with more than 25 years’ experience accidentally took the wrong dosage — vials of 10,000 units of heparin — from inventory and stocked it in the drug cabinet in the newborn intensive care unit, Odle said. Five nurses, who are accustomed to only one dosage of heparin — 10 units — being available, then administered the wrong dose.
The adult and infant doses have similar packaging, officials have said.
Here is a picture of the similar labeling (a mistake waiting to happen) and a second picture showing an error proofed version:
You can see how an error might have occurred in a dark hospital room, early in the morning, with the first picture.
The article continues, in terms of responses:
Starting immediately, Odle said, all Clarian hospitals — which also include Indiana University and Riley Hospital for Children — will no longer keep vials of 10,000 units of heparin in inventory.
Also, all newborn and pediatric critical care units will require a minimum of two nurses to validate any dose of heparin, and two pharmacy workers will be required to check the drugs being loaded into the cabinet. And nursing units will receive an alert when a change in packaging or dose is entered in the drug cabinet.
That seems like a prudent step, not keeping an adult dose of a medication in a children’s hospital.
I would generally worry more about the reliance on inspection as a quality control measure. When you have two people checking something, they might get lax and think “the other person will catch a problem.” Human inspection isn’t 100% effective, even with two people involved… because we’re, well, human and we’re not perfect.
The thing that bothered me the most:
In addition, all employees will be required to sign a document about the importance of correct drug administration by Sept. 23.
Sign a document? That seems like a piece of “patient safety theatre” (along the lines of what some call “security theatre” at the airport).
Having employees sign a document seems to be a very weak form of error proofing. I’d assume that people already KNEW that it’s important to give the proper dose of a medication. People KNOW they shouldn’t make mistakes. But that awareness doesn’t prevent errors when there’s a bad system.
I saw another example at a hospital where nurses where told to sign a poster that highlighted systemic design problems with a brand of infusion pumps often referred to as “the double key bounce.” The sign warned about not punching in the wrong rate (such as hitting 55 instead of 5) and the signature seemed to imply a promise that’s impossible to keep.
Here’s what we’re often expected to promise:
- Promise not to be human.
- Promise not to make mistakes.
- Promise not to be defeated by a device with buttons that sometimes register twice for one push.
We need to do better. How has your hospital progressed in terms of thinking about systems instead of blame since 2007? Has Lean helped in this shift toward proactive prevention of problems?
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