Pa Patient Saf Advis 2016 Jun;13(2):76.
Saves, Safety II, and System Improvements

This narrative introduces a new occasional feature of the Pennsylvania Patient Safety Advisory, highlighting successes by healthcare workers in keeping our patients safe. Safety-II is an approach that assumes that everyday performance variability provides the adaptations that are needed to respond to varying conditions, and that humans are a resource for system flexibility and resilience. The safety management objective is to understand and facilitate everyday work and to maintain the adaptive capacity to respond effectively to inevitable surprises.1 System improvements seek to optimize the complex systems that surround and integrate with healthcare workers’ efforts to provide safe patient care.

Twice as Much Isn’t Twice as Good

Fifty milligrams of a medication was prescribed for a patient.* When the patient’s registered nurse (RN) pulled the medication out of the automated dispensing cabinet, there were 2 pills, each 50 mg, inside the container, equaling 100 mg, however the label said 50 mg. The RN did not administer the med at this time but called the pharmacy to report the problem and sent the faulty container back to pharmacy. The pharmacist and the RN collaborated on checking the other doses in the cabinet. They found that the other doses in the drawer were correct; each contained one 50 mg pill per container. The RN administered the correct dose to patient.

This has been identified as a good catch of a dosage error, based on information available in the event narratives in the Pennsylvania Patient Safety Reporting System. The Authority recognizes and applauds the RN and pharmacist for identifying the mislabeled container, realizing that the error could affect more than one container, and taking the time to check the additional containers.

* The details of the PA-PSRS event narrative in this article have been modified to preserve confidentiality.


  1.       Hollnagel E, Wears RL, Braithwaite J. From safety-I to safety-II: a white paper. The Resilient Health Care Net: Published simultaneously by the University of Southern Denmark; University of Florida, USA; and Macquarie University, Australia. 2015. Also available on Internet:

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