Pa Patient Saf Advis 2019 Mar;16(1).
Safety Stories: Missing the Mark
Anesthesiology, Critical Care, Emergency Medicine, Nursing, Pediatrics, Pharmacy, Surgery
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​This safety story presents a brief, timely highlight of an event reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) that may provide a learning opportunity for facilities.

The Mystery of the Missing Mark

The following event report was submitted through PA-PSRS:*

I started to draw up 1 mL of acetaminophen into a 3 mL syringe. I drew up the medication to the line where "1" was, looked at it, and thought it looked odd. Upon closer inspection, it was actually the 1.5 mL line, but the ".5" wasn't there, and the 1 ml and 0.5 ml lines were also not on the syringe and appeared to have worn off. I checked our supplies and found another 15-20 syringes that also had several numbers worn off; I removed them from our supplies.

The author of this narrative points out the hazard that exists if the individual drawing up medication doesn't recognize that a syringe is incorrectly marked. The reporter is to be applauded for noticing and managing this unsafe condition.

A Resilience Engineering Perspective

The reporter's actions could be described using resilience engineering concepts, as described by Hollnagel.1 Resilient systems include the capacities to—

Monitor: know what to look for. The reporter in this event recognized that the volume of medication didn't look quite right and investigated further to identify that the volume mark was abnormal. This capacity to recognize a subtle defect was based on the reporter's previous experience; expertise can be hard to measure but was a component of this successful save.

Respond: know what to do. Upon recognizing the patient-care hazard, the reporter stopped administering the medication. Further, the reporter considered that the hazard could affect more than the single syringe in hand, and checked the facility's supplies.

Anticipate: know what to expect. The reporter considered that the misleading markings on the syringe might not be obvious to others and proactively minimized future hazard by removing the other affected syringes.

One additional characteristic of resilient systems is the capacity to learn, to know what has happened. The Authority hopes that presenting safety vignettes such as this one, which demonstrate actions that support resilience, will help providers across Pennsylvania (and beyond) provide safe healthcare.

* The details of the Pennsylvania Patient Safety Reporting System event narrative in this article have been contextually deidentified to preserve confidentiality.


  1. Hollnagel E, Braithwaite J, Wears RL, editors. Delivering Resilient Health Care. New York (NY): Routledge; 2019.

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