Mix-up Leads to a Medication Error

In 1995, a 7-year-old boy died when he was injected with what was later discovered to be the wrong medication during routine, elective ear surgery. While this case is remembered for many reasons, most especially for the tragic and unnecessary loss of the young boy's life, it is also remembered within the health care community for the organization's--Martin Memorial Medical Center in Stuart, FL--immediate response and openness in sharing with the boy's family and, later, other health care organizations, the steps taken following the event to prevent such medication administration errors from occurring in the future.

At the time of the event, though neither the medical team nor any staff member knew the cause of the boy's death, the staff and administration of the hospital acted immediately to discover the root causes of the death. An intense and exhaustive investigation revealed a mix-up during the process of transferring medications from the non-sterile field to the sterile field. Less than one month after the boy's death, the hospital instituted a revised procedure that eliminates several steps in the process--and the opportunity for similar errors in the future. The staff of the hospital openly shared the results of their investigation with the field with the hope that other health care organizations would use the experience as an opportunity to scrutinize their own processes and identify and correct any potential areas of risk. More detailed information, including specific recommendations for reducing this type of error, may be found in the March/April 1997 issue of Perspectives, published by Joint Commission Resources, a subsidiary of JCAHO.

Assessing Risk in Medication Use 
This case demonstrates the analysis that should be conducted and the improvement process that should be implemented in response to a sentinel event. Through the process of root cause analysis, one can achieve an understanding of the factors that enabled the event to occur and may lead to process redesign to reduce the risk of that type of event in the future. However, even a root cause analysis, with all its potential for reducing risk, is itself limited by the "blinder" effect of the event. (The blinder effect is the tendency to look only at a part of the process that led to the event, instead of the entire process.)

Through our own and others' experience, we can identify processes that are "high risk." The new patient safety standard in the Leadership chapter of the hospital accreditation manual (LD 5.2) requires hospital leaders to implement a program to reduce the risk of sentinel events and medical/health care errors by conducting proactive risk assessment activities. Each year, organizations are required to select at least one high-risk process for proactive risk assessment, based in part on information published by the Joint Commission, that identifies the most frequently occurring types of sentinel events and patient safety risk factors.

For example, using information presented in this issue of Sentinel Event Alert, an organization may choose to proactively evaluate the process for preparing medications to be administered during sterile procedures. The following chart (Requires Acrobat Reader) summarizes the key steps and findings of a proactive risk assessment using Failure Mode, Effects, and Criticality Analysis (FMECA).

Recommendation
Start identifying and prioritizing the high risk processes in your organization. Using a team approach, conduct your own proactive risk assessments. There are unlimited opportunities to improve patient safety. Don't wait for a sentinel event to occur.