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. That’s why one medical center holds weekly meetings to review all medication-related events reported by frontline staff. Over several months, two participants of this workgroup, a pharmacy manager and quality improvement coordinator, noticed a concerning trend: a bacitracin solution ordered for wound irrigation was being administered through an intravenous (IV) bag instead of through the wound vacuum-assisted closure (VAC) device. Although the error had not yet harmed any patients, these staff members saw an opportunity to make improvements that would keep patients safe.
Recognizing that the mistake was happening because the antibiotic medication was provided in an IV bag, the workgroup queried frontline staff for solutions and consulted with the wound VAC manufacturer about their ideas. This resulted in a product switch to bacitracin in a bottle instead of a bag; the bottle cannot be connected to a patient’s IV, only to the wound VAC for irrigation. The pharmacy manager also worked with the center’s information technology team to change computerized provider order entry for the medication to indicate “irrigation solution” instead of “intravenous solution,” which also removed “intravenous” from printed medication labels, helping to avoid possible confusion. By highlighting an issue before patients were harmed, these event reports and proactive staff kicked off facilitywide innovations in hardware, systems, and processes, preventing more serious adverse events later.
