Event Reporting Category

Categories

Medication

Buttoning Up a System

Electronic Health Record

Communication

Medication

While changing the directions for insulin, a nurse identified that the “No Print” button in her hospital’s electronic medical record (EMR) was sending a prescription (Rx) cancellation to the pharmacy.

Taking Stock of Fluids to Find the Right Solution

Equipment

Medication

Nursing

After a hospital received several event reports of wrong and expired intravenous (IV) fluids caught before reaching patients, the medication safety officer investigated how these products were supplied. This institution purchases all their plain IV fluids from one manufacturer, so the products appear very similar.

Reducing Medication Stock-Outs With New Inventorying System

Medication

The pharmacy department noted several medication error event reports related to patients missing doses or receiving late doses.

Event Reporting Identifies Unanticipated Equipment Failure

Electronic Health Record

Medication

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.

Reducing Risk of Compounding Medication Errors

Medication

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.

Drug Mix-Up in High-Risk Pregnancy Prompts Medication Process Changes

Medication

OB/GYN

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.

Medication Safety Event Reports Lead to Facilitywide Change

Medication

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.

Uncovering a Health Record Error With a Nationwide Impact

Electronic Health Record

Medication

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.

Avoiding Medication Mix-ups

Medication

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.

Standardizing Medication Reconciliation at Discharge

Medication

Transplant Services

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.

Challenges in Patient Hand-Offs Between Hospitals

Communication

Medication

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”).

Collaboration Addresses Long-Standing Problem

Medication

Opioids

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.

Engaging Staff in Solving Safety Issues

Electronic Health Record

Medication

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.