Multiple Swiss Cheese Slices and the Holes Line Up in RN Med Error Case

The following case study is based on closed malpractice claims in the Harvard medical system. Some details have been changed to mask identities.

[Dramatization]

My mom was in the hospital with pneumonia in the ICU. She was getting better, and they were about to move her to a regular room, when it happened. A nurse gave her the wrong drug and way too much and she never recovered. Now she’s gone.

[Narration:]

A nurse in an under-staffed medical ICU was caring for two patients. One patient was there for blood pressure management with vasopressor Norepinephrine. The second patient was being treated with the antibiotic Bactrim for pneumonia. This patient was progressing well and was scheduled for transfer to a step-down unit once a bed became available.

The nurse called the pharmacy and requested both the Norepinephrine and Bactrim be sent to the unit. Around 6:30 p.m., the nurse administered the Norepinephrine instead of the Bactrim for the patient with pneumonia. The medication rate was also triple the maximum for that drug because the rate was selected for the other drug. The nurse did not complete the required safety checks before starting the medication.

Around the shift change, the oncoming nurse noted the patient’s blood pressure was 220’s systolic. The nurses did not recognize the error and discussed possible causes of an elevated blood pressure. They thought it might be abdominal pain or maybe it was anxiety related to the upcoming transfer. The overnight nurse rechecked the patient’s blood pressure and noted it remained elevated. The patient was also experiencing a fast heart rate and increased, labored breathing.

The nurse called the resident, who noted a cardiac rhythm on the monitor concerning pulseless electrical activity (PEA), and then called a code blue. The charge nurse, who was assisting with the code, discovered the wrong name on the medication, and stopped the infusion. Unfortunately, the code was unsuccessful, and the patient died that night about two hours after the medication mix-up.

An investigation concluded that the medication error precipitated the code and the patient’s death. In the malpractice action against the nurse, the patient’s family alleged that a failure to follow safety protocols when administering medications contributed to the patient’s death, and the case was settled for more than $1M.

Joining us now to discuss the risk, management and patient safety implications of the case is Julie Higden. Julie is an RN and Senior Program Director of Patient Safety for CRICO in the Harvard System.

Tom Augello: Thank you, Julie, for joining us.

Julie Higden Hi Tom, Thanks for having me.

Tom Augello: Now we know from the research into medical error that errors that result in harm are often the result of a cascade of mistakes or vulnerabilities in a system, not the individual at the sharp end of the process. Yet that final administrative step in the medication process is the last line of defense.

Julie Higden: Yes. So the administration step in the medication process is considered the last line of defense, because it is the step where the medication error could potentially reach the patient. And there's things that we can do like verifying the five rights of medication administration, which is essential to maintaining safety, and some might argue that there's even more than five rights. But that's one thing we can do to really mitigate the risk at the administration process of care step.

Tom Augello: When we evaluate other malpractice claims like this, what are sort of the typically most important contributing factors that come out of those codes?

Julie Higden Well as we know, there's rarely, if ever, just one contributing factor in a case. There's typically many, and I think they're certainly all important. But when we analyze these cases, we're seeing now more often, I think the influence that the care environment has on outcomes, and these are more of what we would consider contextual factors, such as things like the busyness of a unit, staffing shortages, nights and weekends, distractions, heavy workloads, interruptions, and so forth. And there's also personal factors, such as fatigue or inattentiveness, and in this case, in particular, I think many of those factors contributed here.

We also see often in claims, factors related to communication. These are really vital to understand. And in this case I think a lack of a proper handoff may have contributed, so we often see improper handoffs which can include shift to shift, clinician to clinician and interdepartmental transfers as well. And really there should be a systematic and comprehensive handoff happening at shift changes at the bedside, which include elements such as assessment of the patient, the situation, and a review of medications.

And of course there's lack of adherence to policies and protocols in this case, again, not utilizing barcode administration scanning which, as we know, is an intervention that's in place for good reason. We know that most medication errors as we talked about happened during that administration phase of care, and so adherence to barcode scanning is really vital to catching the potential medication errors before they reach the patient.

Tom Augello: To what extent do you think patient assessment played a role in this case?

Julie Higden: There are many factors in particular that played a role in this case, and patient assessment is certainly one of them. Once the incorrect medication was administered, and the patient was experiencing that extreme hypertension. The nurses noted that perhaps pain or anxiety was an underlying cause.

At this point additional data points could have been captured. This would have been a time to pause and complete a full assessment of the patient. So it's important to look at the whole patient, the environment, the medications, and other factors that could be contributing to a drastic change in status. So I do think the patient assessment did play a significant role in this case.

Tom Augello: What's at the top of your list of things that institutions and individuals could or should do to help prevent this kind of medication error?

Julie Higden Yeah, well these are such complex issues, and I think rarely have a straightforward or an easy answer. I think there's a few things that can be done to support safe care and prevention of medical errors.

This is not an easy one, but support for adequate staffing is always a challenge, but I think vital to clinicians being able to provide safe care; ongoing education, again, adherence to barcode administration and scanning and understanding the importance behind that; education again, around the five rights of medication administration. Even if you are a senior staff member and you've done this dozens of times, it’s important to slow down even during busy times, reading and rereading labels, checking pumps, double checking medication doses, focusing on those structured handoffs. These are all things that we can do. And I think ultimately creating a non-punitive culture of safety and learning from these near misses, so staff can learn from events hopefully before they reach and harm a patient, are all things that we can do to mitigate risk.

Tom Augello: Well, thank you very much for these insights today, Julie.

Julie Higden Thank you for having me, Tom.

Tom Augello: Julie Higden, nurse and Senior Program Director of Patient Safety for CRICO. I'm Tom Augello.