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The Case NSG468wk4 docx

The Case NSG468wk4 docx

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The Case

A previously healthy 50-year-old man was hospitalized while recovering from an

uncomplicated spine surgery. Although he remained in moderate pain, clinicians planned to

transition him from intravenous to oral opioids prior to discharge. The patient experienced

nausea with pills but told the bedside nurse he had taken liquid opioids in the past without

difficulty.

The nurse informed the physician that the patient was having significant pain, and liquid

opioids had been effective in the past. When the physician searched for liquid oxycodone in

the computerized prescriber order entry (CPOE) system, multiple options appeared on the

list—two formulations for tablets and two for liquid (the standard 5 mg per 5 mL

concentration and a more concentrated 20 mg per mL formulation). At this hospital, the

CPOE system listed each choice twice, one entry with the generic name and one entry with a

brand name. In all, the physician saw eight different choices for oxycodone products. The

physician chose the concentrated oxycodone liquid product, and ordered a 5-mg dose.

All medication orders at the hospital had to be verified by a pharmacist. The pharmacist

reviewing this order recognized that the higher concentration was atypical for inpatients but

assumed it was chosen to limit the volume of fluid given to the patient. The pharmacist

verified the order and, to minimize the risk of error, added a comment to both the electronic

medication administration record (eMAR) and the patient-specific label that the volume to be

given was 0.25 mL (5 mg). For added safety, the pharmacist personally retrieved, labeled,

and delivered the drug and a calibrated syringe to the bedside nurse to clarify that this was a

high concentration formulation for which the volume to administer was 0.25 mL (a smaller

volume than would typically be delivered).

Shortly thereafter, the nurse went to the bedside to administer the drug to the patient for his

ongoing pain. She gave the patient 2.5 mL (50 mg) of liquid oxycodone, a volume that she

was more used to giving, and then left for her break. A covering nurse checked on the patient

and found him unconscious—a code blue was called. The patient was given naloxone (an

agent that reverses the effect of opioids), and he responded well. He was transferred to the

intensive care unit for ongoing monitoring and a continuous infusion of naloxone to block the

effect of the oxycodone. By the following morning, the patient had returned to his baseline

with no apparent adverse effects.

The Commentary

Medication errors in the hospital are all too common. Although it may seem that the only

error in this case was the nurse giving the wrong amount of medication to the patient, many

latent errors contributed to harm reaching the patient. Medication errors are rarely caused by

failure of a single element or the fault of a single practitioner.(1) For example, in a root cause

analysis (RCA) of a fatal medication error in which a nurse administered the wrong

medication by intravenous route, an external review found four main proximate causes and

multiple performance-shaping factors that contributed to the event.(2) To prevent similar

errors from occurring, the reviewers identified more than 15 suggested changes that spanned

the medication use system at the hospital.(2) Because medication errors are often

multifactorial, analysis of errors should always identify weaknesses in the system and

corrective plans should include risk reduction strategies that span multiple processes.

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Systems Approach to Medication Errors

The goal of a system-based analysis of errors is to discover underlying system failures that

are amenable to correction. In their landmark study using a systems analysis of adverse drug

events, Leape and colleagues identified several domains where underlying problems

occurred. These domains included lack of information about the patient, drug stocking and

delivery problems, and inadequate standardization.(3) Similarly, the Institute for Safe

Medication Practices (ISMP) has identified 10 key system elements that have the greatest

influence on safe medication use (Table 1).(4) Although other categorizations also exist, this

commentary will use ISMP's model to analyze the case. Readers who also wish to analyze

errors in this manner can use a worksheet available on ISMP's Web site

(http://www.ismp.org/tools/AssessERR.pdf).

Developing Effective Risk Reduction Strategies

Identifying errors in the system may indicate where changes need to be made. There are two

objectives of safe system design: (i) to make it difficult for individuals to make mistakes and

(ii) to permit the detection and correction of errors before harm occurs.(3) However,

designing effective strategies to make the system safer is difficult. It is easy to implement low

leverage strategies ("weak" interventions) as a quick fix for an error. For example, a simple

response to this case would be to tell the nurse to read the medication label and electronic

medication administration record (eMAR) more carefully, the pharmacist to give better

instructions, and the physician to be more careful when using the CPOE system. Such

strategies are unlikely to prevent an error from occurring again as they rely on humans to

avoid mistakes. Instead, higher leverage strategies ("strong" interventions) that prevent

human errors from propagating through the system should be implemented.

In the rank order of error-reduction strategies (Table 2), high leverage strategies create lasting

change in the system. Fail-safes, constraints, and forcing functions are types of strategies that

improve the system with minimal reliance on human vigilance and memory. On the other

hand, providing education and information and drafting rules and policies are easy to

implement but often rely on human vigilance. These low leverage strategies are likely to only

be effective if combined with interventions that target systems issues.(5,6)

System-Based Analysis

A robust system-based analysis of this error might discover failures that are amenable to

higher leverage solutions to prevent future occurrence. Rigorous analysis of medications

errors should use the ISMP model and examine the 10 key system elements (Table 1).

Applying the framework in the analysis of this case reveals a substantial number of failures

and areas for clear system improvement.

Patient Information

Both the pharmacist and the physician in this case were likely unaware of key patient

information which may have contributed to the error. For example, the physician may not

have known the patient's opioid-use history, such as which liquid opioid he used in the past,

and thus could not reorder that specific medication and dose. It appears the pharmacist was

not directly aware of the patient's opioid use in the past and assumed the patient was a

candidate for concentrated oxycodone. To prevent similar gaps in the future, the institution

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The Case A previously healthy 50-year-old man was hospitalized while recovering from an uncomplicated spine surgery. Although he remained in moderate pain, clinicians planned to transition him from intravenous to oral opioids prior to discharge. The patient experienced nausea with pills but told the bedside nurse he had taken liquid opioids in the past without difficulty. The nurse informed the physician that the patient was having significant pain, and liquid opioids had been effective in the past. When the physician searched for liquid oxycodone in the computerized prescriber order entry (CPOE) system, multiple options appeared on the list—two formulations for tablets and two for liquid (the standard 5 mg per 5 mL concentration and a more concentrated 20 mg per mL formulation). At this hospital, the CPOE system listed each choice twice, one entry with the generic name and one entry with a brand name. In all, the physician saw eight different choices for oxycodone products. The physician chose the concentrated oxycodone liquid product, and ordered a 5-mg dose. All medication orders at the hospital had to be verified by a pharmacist. The pharmacist reviewing this order recognized that the higher concentration was atypical for inpatients but assumed it was chosen to limit the volume of fluid given to the patient. The pharmacist verified the order and, to minimize the risk of error, added a comment to both the electronic medication administration record (eMAR) and the patient ...
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