Pa Patient Saf Advis 2018 Mar;15(1).
Safety Stories
Anesthesiology, Emergency Medicine, Internal Medicine and Subspecialties, Obstetrics and Gynecology, Pediatrics, Surgery
Expand All Collapse All

"Safety Stories" (previously "Saves, System Improvements, and Safety-II") is an occasional feature in the Pennsylvania Patient Safety Advisory, highlighting successes of healthcare workers in keeping patients safe. The Safety-II approach assumes that everyday performance variability provides adaptations needed to respond to varying conditions and that humans are a resource for system flexibility and resilience.1

What's Missing?

The following event report, submitted through the Pennsylvania Patient Safety Reporting System (PA-PSRS),* illustrates the value of a systems perspective:

Upon collecting a patient's specimen, the RN [registered nurse] noted that the buffer vial did not contain liquid buffer. She obtained another collection kit, collected the specimen, and submitted it to the lab for testing. Staff examined the other collection kits and found another buffer vial that was empty. Lab Director notified the manufacturer.

It can be difficult to identify when a component of a system is missing. It is often easier to identify that a part is present, but is crooked or the wrong size or color. The Authority applauds this nurse for her alertness in recognizing that a necessary element of a vial was missing.

In addition, the Authority congratulates this nurse and her facility team for not just improving safety for the single patient who was almost affected, but for applying a systems perspective by investigating whether other vials might have a similar problem. After finding more than one problematic vial, the facility notified the manufacturer, so that the problem could be evaluated and mitigated at the point of manufacture. This system perspective will likely enhance the safety of patients in multiple facilities.

The Authority commends the nurse and her facility for recognizing a problem and seeking to correct the problem at its source.


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


  1. Braithwaite J, Wears RL, Hollnagel E. Resilient health care: turning patient safety on its head. Int J Qual Health Care. 2015 Oct;27(5):418-20. Also available: PMID: 26294709.

The Pennsylvania Patient Safety Advisory may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration, provided the source is clearly attributed.

Current and previous issues are available online at

©2020 Pennsylvania Patient Safety Authority