Medication Sentinel Events in Wisconsin
PDF Version of BQA 06-024
(PDF 28 KB)
Date: October 11, 2006 -- DDES BQA Memo 06-024
From: Douglas Englebert, Pharmacy Practice Consultant
Provider Regulation and Quality Improvement Section
Bureau of Quality Assurance
Via: Otis Woods, Director
Bureau of Quality Assurance
Medication Sentinel Events in
Two avoidable medication events,
leading to unfortunate patient deaths, recently occurred in Wisconsin
hospitals. This memo describes these events and describes some practices
for providers to consider in order to prevent such incidents from
occurring in their facilities.
Case #1: This case involves a medication being given via the
wrong route. A pregnant woman was admitted to the hospital for induction
of labor. This hospital uses a bar code medication administration system.
The system involves scanning the patient's wrist band bar code and the
medication bar code to ensure that the medication being considered for
administration has been ordered for the patient.
An intravenous antibiotic was ordered to be given to this patient prior
to delivery. In preparation for the induction of labor, the patient was
provided with information on the use of an epidural anesthetic. As part of
the epidural education, a bag containing the epidural medication was
obtained from the automated medication storage device to show to the
patient. Both the antibiotic and the epidural bags were at the patient's
bedside. During the medication administration process, the epidural bag
was confused with the bag containing the antibiotic, and instead of the
antibiotic, the epidural anesthetic was administered intravenously. The
bar code system was not used. Unfortunately, the patient expired.
Considerations: This case
serves to highlight some system practices that may prevent similar
occurrences. One possible practice is the use of warning labels or
packaging to alert staff that a medication is not for IV administration.
In this case, warning labels were in place on the epidural bag indicating
"Epidural Use Only," but the warning was not heeded.
Accordingly, facilities should analyze and confirm that staff recognize
and adhere to the warning labels being used in the facility.
Another practice to consider is the creation of an epidural training
kit that contains materials to educate patients about epidurals without
having to use the actual drug from the automated medication storage
device. Additionally, medical and pharmacy staff should conduct an
evaluation of medications contained in automated medication storage
devices to determine whether access overrides should be allowed for
epidural preparations. These are just a few of the practices that can be
adopted to prevent errors of this type.
Last, but not least, bar code systems and other interventions that
facilities have adopted to prevent medical errors require regular
monitoring and staff training to ensure that system protocols are followed
and are effective.
Case #2: This case involves the errant intrathecal
administration of a "not for intrathecal use" contrast medium.
The improper administration of the contrast medium occurred in radiology
and led to the patient's death.
Mix-ups involving IV and intrathecal contrast media have been
previously reported, leading the Food and Drug Administration to issue
warnings, including required label changes by the contrast media
manufacturers. Other organizations, such as the Institute for Safe
Medication Practices, have also addressed this issue.
Considerations: This case serves as a reminder that contrast
media are medications for which pharmacy has oversight responsibility.
Pharmacy must be involved in the ordering, storage, and administration
policies related to contrast media. Education of staff, including
radiology staff, regarding administration of contrast media is important.
System considerations include separating different types of contrast
media, using warning labels for the route of administration, and
developing double-check systems for all preparations intended for
intrathecal administration. The following link provides some other
recommendations for contrast media. http://www.ismp.org/Newsletters/acutecare/articles/20031127.asp?ptr=y
The Department of Health and Family Services urges all
facilities to undertake a complete analysis of their medication systems.
This memo outlines some considerations related to system evaluation and
improvement. Another factor to consider is that all medication systems
involve people at some point, and this means that facilities need to
examine the human components of their systems. That may mean promoting a
culture of continuous quality improvement, including evaluations of
clinical care processes. Systems are an important part of the care
process, but the ability of staff to function safely within those systems,
should not be overlooked.
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