How is this error even possible?

[Sparda29]

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http://www.nydailynews.com/news/national/brain-surgery-patient-dies-wrong-drug-article-1.2038982

Woman was supposed to get fosphenytoin drip but got a rocuronium drip instead. You know someone's getting fired here.

 

[Sparda29]

People don't read.

It's not even close together on the alphabet.

 

[njac]

It's not even close together on the alphabet.

Someone put it in the wrong bin in the fridge.

**** happens. This is why you check every single vial when the techs are doing Pyxis fills.

 

[njac]

I never approach an error with "how the hell did this happen!?" Because **** happens.

Even if it's not an error you would make, it's important to assess how it came to be and what steps need to ensure it never happens again.

What terrible timing for a fire alarm!

 

[confettiflyer]

Would love to read the RCA on that one.

 

[BenJammin]

I've learned that the stranger it sounds, the more likely it is to happen. We had a HUGE dispensing error at our outpatient pharmacy where phenazopyridine 200 mg was dispensed instead of amiodarone 200 mg. They're not on the same shelf, not in the same section, bottles look nothing alike, tablets look nothing alike, and yet it still made it out of the pharmacy. She comes into the emergency room complaining of blood in her urine yet her labs looked perfect and urinalysis was perfect. I made a joke to the attending that she probably got ahold of pyridium. That joke became reality.

 

[Sparda29]

I'll await you making a similar error one day in your career.

I've made an error where I dispensed Vancomycin 5 mg/ml instead of 10 mg/ml. Assumed that 5 mg/ml was the only concentration we made it in and that the label was a typo in product selection.

 

[xiphoid2010]

http://www.nydailynews.com/news/national/brain-surgery-patient-dies-wrong-drug-article-1.2038982

Woman was supposed to get fosphenytoin drip but got a rocuronium drip instead. You know someone's getting fired here.

I just called pharmacy and nursing together for a short teachable moment on this case earlier today. All of our paralytics are sealed with a warning label, and they are kept separately because of horror stories like this. But it is hy hospital medicine can not be treated retail. I know my staff and nurses whine when I write them up for errors, but I wanted to show the difference between a near miss and a sentinel event is just one second away.

 

[Ackj]

How is it possible? Trying to hurry up and pulled a bunch of vials and brought them all in the hood to make a bunch of bags. From there, it could be the vials got arranged wrong, the labels got shuffled, same product made twice, etc. Doesn't matter if they aren't alphabetically close or even if they are stored in different areas if you pull a bunch at the same time.

 

[zelman]

How is it possible? Trying to hurry up and pulled a bunch of vials and brought them all in the hood to make a bunch of bags. From there, it could be the vials got arranged wrong, the labels got shuffled, same product made twice, etc. Doesn't matter if they aren't alphabetically close or even if they are stored in different areas if you pull a bunch at the same time.

Who would do something so foolish? That reminds me of a complaint someone had about a pediatric hospital....

Telling you to complete the IV log as you go along as opposed to completing all the IV log work before you start or after you finish. Makes it absurdly hard to work quickly.

 

[BidingMyTime]

How is it possible? Trying to hurry up and pulled a bunch of vials and brought them all in the hood to make a bunch of bags. From there, it could be the vials got arranged wrong, the labels got shuffled, same product made twice, etc. Doesn't matter if they aren't alphabetically close or even if they are stored in different areas if you pull a bunch at the same time.

This. This is exactly how an error like that can happen.

And as Zelman points out, Sparda I remember you defending grabbing all your supplies at once, do you see why hospitals have rules against this?

What a tragic error. Even when all the rules are followed, human error still occurs. But following the rules to a T dramatically cuts down errors.

 

[mustang sally]

So then the tech put the empty fosphenytoin vials by the roc drip for checking?

Just wondering how it got past the pharmacist...

 

[WVUPharm2007]

We are expected by the public to be perfect. Unfortunately, we aren't. Every damn one of us will make mistakes of varying degrees of importance. I'm yet to harm someone, but I've made mistakes. When I was an intern, I put adult strength Vitamin K into the neonatal strength Pyxis bin. Granted, the pharmacist checked it, but I still felt to blame. Nothing bad happened, but it kept my up all night for a while. When I was in the hospital gig, I never did anything major, but I did small stupid things like have two doses of omeprazole being given rather than one. Its easy to see how I could have harmed someone. In retail, I dispensed Depakote ER rather than DR. Thankfully, theperson didn't have a seizure.

Nothing bad happened in each case, but I know damn well its just total luck. I just feel bad for this pharmacist. EVERY PHARMACIST MAKES MISTAKES. Its just luck of the draw for who makes the fatal one. Its an unfortunate sort of Russian Roulette.

 

[Sparda29]

This. This is exactly how an error like that can happen.

And as Zelman points out, Sparda I remember you defending grabbing all your supplies at once, do you see why hospitals have rules against this?

What a tragic error. Even when all the rules are followed, human error still occurs. But following the rules to a T dramatically cuts down errors.

True, but I was talking about drawing up PO syringes like multi-vit, ferrous sulfate, amoxicillin, etc.

I had no problem with writing things down as you go along. I had a problem with having to change gloves/wash hands every time I had to use my pen.

IV pharmacists. How many gloves would you say you go through per shift?

 

[lapharmacienne]

Depends on how many TPN and chemo I have to check...about 10 on average

 

[Dred Pirate]

True, but I was talking about drawing up PO syringes like multi-vit, ferrous sulfate, amoxicillin, etc.

I had no problem with writing things down as you go along. I had a problem with having to change gloves/wash hands every time I had to use my pen.

IV pharmacists. How many gloves would you say you go through per shift?

alcohol down your pen and you can take it into the clean room - that is what we do

 

[Sparda29]

alcohol down your pen and you can take it into the clean room - that is what we do

That's what I thought also, but the management here didn't like that.

 

[BidingMyTime]

IV pharmacists. How many gloves would you say you go through per shift?

I have thought about how hospitals are probably contributing to the destruction of the environment. The amount of garbage & waste from just 1 day of the IV room (and think about all the other departments generating similar amounts) is astounding. Still, it beats the alternative of not being clean.

 

[Dred Pirate]

When reading about these errors it always gives me a chance to make myself slow down. I work very fast, and have never made a mistake that led to patient harm, but I realize how easily it is if just one of those vials that I checked, mixed, put in pyxis, etc was wrong, how disastrous the results would be.