PA PSRS Patient Saf Advis 2006 Sep;3(3):12-13.
Looking Beyond the Obvious Causes of Error

Looking Beyond the Obvious Causes of Error

To truly understand the underlying causes that can lead to medication errors, we must first understand the medication use system. This system is a complex group of related processes that includes obtaining patient information, communicating drug orders, storage of medications, labeling and packaging of medications, patient education, medication administration, and environmental factors.

Medication errors are a property of this system as a whole, rather than purely the result of the acts or omissions of the people who interact with the system. Even when an error is due to the mistake of an individual, deeper investigation will likely determine that a variety of causes contributed to that individual’s perceived failure. Such causes could include:

  • Poor order communication between the physician, nurse, and pharmacist.
  • Dangerous medication storage practices.
  • Look-alike packaging and labeling.1

Unfortunately, when analyzing errors, some organizations tend to focus only at the active or “sharp end” of the error: the frontline practitioner most directly associated with it, such as the prescriber who wrote an order, the pharmacist who dispensed the medication, or the nurse who administered it. Some healthcare practitioners are taught early in their careers that they must be perfect—an unattainable and unrealistic expectation for any human.

When errors occur, the human tendency is to blame individuals. Those individuals blamed for the errors are considered to be inattentive, incompetent, lazy, or uncaring, and they are often subject to punitive action (Table 1) such as disciplinary action, private reprimands, remedial education (e.g., to follow the “5 rights”2), or termination. As a result, the practitioners involved may feel guilty and unworthy of their professional status.

​Table 1. Examples of Punitive Approaches to Error Reduction
  • Private reprimand
  • Public reprimand
  • Written reprimand
  • Remedial education
  • Point system
  • Errors recorded in performance appraisal
  • Appearance before a peer review committee
  • Termination

 

In this type of environment, it’s not surprising that individuals may be tempted to hide future errors. In the end, punitive actions do little, if anything, to prevent the same error from happening again within the organization. It does nothing to focus attention on the most manageable component of an error: the system itself.

Effective analysis considers the latent failures that led to the error. Latent failures (also called contributing factors or “blunt end” failures) are weaknesses in organizational structures that support medication processes. These failures range from poor planning for an information management system to inadequate personnel training and education. Many of these failures are due to poor decisions made by management.3 By themselves, latent failures often are subtle and may not appear to directly cause an error. Their individual consequences are usually hidden, becoming apparent only when they occur together and in combination with failures or “slips” made by individuals at the “sharp end.”4 Examples of latent failures can be found in Table 2.

​Table 2. Examples of Latent Failures
  • Incomplete patient information, such as missing allergy or diagnosis information
  • Unclear communication of a drug order
  • Lack of independent double checks before dispensing
  • Lack of computer warnings or alerts
  • Ambiguous drug references
  • Drug storage issues
  • Unclear policies/procedures

 

This medication error report submitted to PA-PSRS includes several latent failures that led to the wrong medication reaching a patient:

A nurse entered the organization’s automated dispensing cabinet (ADC) to obtain a 2 mg dose of morphine to be given intravenously to a patient. The ADC screen read “morphine sulfate 8 mg tubex.” Instead of taking this dose and following the procedure for wastage, the nurse hit the override key, and the screen then listed every type of morphine sulfate available. The nurse then selected the first medication listed at the top of the screen, which read “morphine sulfate 2 mg/mL.”

The drawer to the ADC opened, and the nurse removed the bottle. The bottle was unopened, and the nurse was unsure how to withdraw the medication. A second nurse told her to get a syringe and draw up one milliliter. The nurse administering the medicine noticed that the color of the solution was blue. The second nurse came back and asked, “Did you have to mix it?” The first nurse responded, “Oh no, I gave it intravenously.” The second nurse responded, “I thought you were giving it orally.”

Through our experience in reviewing medication errors, some possible contributing factors that led to this patient receiving an oral solution of morphine sulfate intravenously include the following:

  • The strength of morphine available to the nurse was four times the dose needed. This led the nurse to seek another strength, since she was unwilling to waste the left over medication in the 8 mg tubex of morphine to administer the 2 mg dose.
  • The list of medications that appeared on the ADC screen listed “every type of morphine sulfate available” instead of only those stocked in the ADC. In addition, all dosage forms of morphine were included (oral tablets, oral solutions, and injections).
  • The description of the oral solution as “morphine sulfate 2 mg/mL” on the ADC screen did not indicate that this medication was an oral solution.
  • The ADC was stocked with a multi-dose bottle of the oral morphine solution, instead of unit-dose cups.
  • There was no pharmacy review of the order prior to administration of the medication.
  • There was no independent double check of this high-alert medication while it was in the syringe to verify the correct dose prior to administration.
  • Staff may have been unaware of the dangers of over-riding alerts or of high-alert medication procedures, such as an independent double check.

Reducing medication errors requires an effective, non-punitive reporting environment, an effective reporting system, and a multidisciplinary group to analyze the error reports. Armed with these tools, facilities can identify system deficiencies and make performance improvement changes to prevent harm to your patients. Without them, we are only addressing errors when they surface, rather than reviewing the cause. To proactively prevent errors from occurring in the future, they must be reported, within your organization, as well as to state reporting programs such as PA-PSRS and others, and the contributing factors need to be identified. A cursory analysis focused on the front-line practitioner at the “sharp end” ignores the potential latent errors that can contribute to the same error recurring.

Organizations with an eye towards safety that encourage reporting of actual errors, “near misses” and even potentially hazardous conditions will gain rich information about the factors that may lead to an error.5 Where medication errors are concerned, the question of who was involved offers less information than what went wrong, how it happened, and why it occurred. A systems perspective begins with the assumption that errors will occur in the healthcare setting and that the multi-factorial nature of errors is system-based, not people-based. Most importantly, if we are going to strive to improve medication safety, we must focus on redesigning the system that may have led individuals down a path of failure.

Notes

  1. Wunderlich GS, Kohler P, Eds. Improving the Quality of Long-Term Care: Institute of Medicine Report, December 13, 2000. Available from Internet: http://books.nap.edu/books/0309064988/html/index.html/.
  2. Pennsylvania Patient Safety Reporting System. Patient Safety Advisory. The Five Rights: Not the Gold Standard for Safe Medication Practices [online]. Available from the internet: http://patientsafetyauthority.org/advisories/advisorylibrary.
  3. Reason J. The contribution of latent human failures to the breakdown of complex systems. Philos Trans R Soc Lond B Biol Sci. 1990;327:475-84.
  4. Institute for Safe Medication Practices (ISMP). Medication Safety Alert! Acute Care Edition. 11 Feb 1998;(3)3.
  5. ISMP. Medication Safety Alert! Community/Ambulatory Care Edition. Sep 2003;(2)9.

Supplemental Material

Self-Assessment Questions

The following questions about this article may be useful for internal education and assessment. You may use the following examples or come up with your own.

  1. Latent failures can be described as:
    1. weaknesses in the design and structure of an organization
    2. weaknesses in individual practitioners
    3. mistakes by practitioners
    4. none of the above
  2. Most medication errors occur due to:
    1. individuals not paying attention to tasks
    2. violations of rules or policy
    3. faulty medication system design
    4. individual incompetence
  3. Examples of punitive actions taken by organizations in response to an error include:
    1. using information about the error during performance evaluations
    2. accumulation of demerits or points for each error reported
    3. requiring individuals involved in errors to obtain special education
    4. all of the above
  4. Contributing factors that led to the medication error in this article include:
    1. The list of medications that appeared on the ADC screen listed “every type of morphine sulfate available” instead of only those stocked in the ADC.
    2. The description of the oral solution as “morphine sulfate 2 mg/mL” on the ADC screen did not indicate that this medication was an oral solution.
    3. The ADC was stocked with a multi-dose bottle of the oral morphine solution, instead of unit-dose cups.
    4. There was no pharmacy review of the order prior to administration of the medication.
    5. There was no independent double check of this high-alert medication while it was in the syringe to verify the correct dose prior to administration.
    6. All of the above.
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