Pa Patient Saf Advis 2008 Jun;5(2):63.
“Manager Spoke with RN Involved: Reviewed Policy No. 750”

The response says it all!

The following report was submitted through PA-PSRS (some information in this report has been altered to deidentify the facility):

The [infant] patient received 500 mg (100 ml) bag of Flagyl® instead of 27.3 mg (5.46 ml). The outer bag was labeled 27.3 mg/5.46 ml but the inner bag was labeled from the manufacturer [500 mg (100 ml)]. . . . RN used outer pharmacy label when verifying correct medication, correct patient, and correct dose. [RN] did not read manufacturer bag prior to hanging medication. . . . Manager spoke with RN involved: reviewed policy No. 750. . . .

Apparently, in the minds of administrators in this facility, the nurse (i.e., RN) had failed to either read or remember policy No. 750; had he or she done so, the error would not have occurred.

The patient safety analysts saw it differently, as follows:

  • A person can’t be expected to remember 750-plus policies.
  • The organization may believe that “following policies and procedures” is an effective strategy to prevent errors. Patient safety experts know that patient safety solutions that are expecting humans to ”be more careful,” such as “follow the five rights,” are ineffective system solutions.
  • The labeling was ambiguous, increasing the risks of an inadvertent human error.
  • The best way to avoid an overdose is to not deliver enough drug to the bedside to have an overdose. This medication error was due to the RN thinking he or she had to deliver the entire 100 ml. Had the nurse programmed an IV pump to deliver the correct amount, another error could have still resulted in the delivery of the full 100 ml overdose.
  • From a nursing perspective, having a pharmacy technician prepare the medication as a unit dose that is checked by a pharmacy and labeled with the total dose and mg/ml will allow the nurse to triple check the infusion rate against the order. Obviously, pharmacy needs to have its own systems in place to prevent the error. The pharmacy could also send the medication in a syringe pump that doesn’t allow large amounts of fluids to be administered.

The patient safety analysts believe a better solution would have been to deliver unit doses to the bedside, hopefully eliminating the need for every provider to remember policy No. 750 with every patient encounter to avoid an overdose.


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