The pharmacy department noted several medication error event reports related to patients missing doses or receiving late doses.
An organization reported several heparin infusion events over a year, which prompted several process changes in the electronic health record with the acknowledgement of orders, views within the medication administration record, and labeling of intravenous lines.
As part of a facility’s efforts to become a high reliability organization (which maintains high levels of safety, quality, and efficiency) to achieve zero patient harm, they turned their attention to addressing reports of medication errors related to preparing intravenous (IV) products.
A woman in her second trimester (24 weeks gestation), who had experienced two prior fetal losses at 18 and 20 weeks respectively and had undergone a cervical cerclage (closing the cervix with stitches to hold a pregnancy) about a month earlier, presented to the hospital with intermittent contractions.
Event reports do more than simply record what went wrong—they’re an important way to communicate issues so things can go better next time.
While rounding with an inpatient team, a clinical pharmacist identified that a patient’s medication list contained two medications to prevent stroke and heart attack, ticagrelor and atorvastatin, with no apparent indication.
Look-alike, sound-alike medications are a contributing factor in wrong drug medication errors, because the similar names are easily mixed up—presenting a high risk of patient harm.
A safety event involving a discharged patient taking too much of a prescribed medication prompted a facility’s liver transplant and clinical leadership teams to perform a root cause analysis.
A patient with acute thrombus—a blood clot in a vein or artery—was being transferred from an emergency department at a small outlying facility (“transferring facility”) to the intensive care unit (ICU) at a larger hospital (“receiving facility”).
Medication safety committees regularly review medication errors and near misses. During one such review, the med safety committee at one hospital recognized issues with the way opioids were being ordered via the patient-controlled analgesia (PCA) pumps, including the availability of multiple concentrations of drugs which could be administered in the wrong amount to a patient.
After a health system experienced multiple events in which a patient received an insulin injection with another patient’s pen, with no improvements following root cause analysis and process changes, the safety team published an article in their patient safety newsletter soliciting ideas from staff.