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a woman laying in a hospital bed with an IV in her hand.
Drug Mix-Up in High-Risk Pregnancy Prompts Medication Process Changes
​​​​​​​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. The certified nurse midwife (CNM) placed a medication order in the electronic medical record (EMR) for Prostin (diaprostone), which is used for cervical ripening and labor induction, when she meant to order Prometrium (progesterone), used to help prevent premature labor. Fortunately, the charge nurse recognized that the wrong medication had been ordered and administered to the patient as she reviewed the patient’s dietary orders. The primary nurse immediately removed the Prostin vaginal suppository and interventions were implemented to prevent premature labor.

Analysis of the event revealed a number of contributing human factors, beginning with the brand names of both medications in the dropdown list beginning with PRO. Although the primary nurse questioned the frequency of the medication dosing schedule, as Prometrium is usually ordered daily, the CNM only altered the frequency, not the medication ordered. The pharmacist was new to the profession and the organization, without complete information about the patient, and did not catch the incorrect medication order or how it conflicted with another order for betamethasone, a drug to speed up lung development in premature infants. The EMR team reviewed the ordering sequence by the CNM and implemented changes to prevent the error from reoccurring: Prometrium vaginal capsules were added to the preference list search showing the brand name and Prostin was removed from the formulary, as it is rarely used. This event was discussed broadly in Just Culture open forums to create situational awareness about confirmation bias and to reinforce the importance of referencing medications to ensure that the medication is indicated for the clinical reason being treated.​


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