Using Information From External Errors to Signal a “Clear and Present Danger”


By the Institute for Safe Medication Practices

Chances are you’ve scanned the headlines and read many of the stories about medication errors, particularly the tragic errors. Just a few examples of the tragic errors that ISMP has published in the past few years include:

  • The death of a 2-year-old boy who placed a used fentaNYL patch in his mouth after he ran over it with his toy truck in his great grandmother’s room at a long-term care facility
  • A 4-year-old boy who died after he was given oral chloral hydrate before a procedure and was strapped onto a papoose board without proper positioning of his head to protect his airway
  • An unventilated trauma patient who died after receiving intravenous (IV) vecuronium when a physician mistakenly entered an order for the paralyzing agent into the wrong patient’s electronic record
  • A 65-year-old woman who died in the emergency department after receiving IV rocuronium instead of fosphenytoin
  • A 43-year-old woman who died because of an accidental overdose of fluorouracil that was administered over 4 hours instead of 4 days
  • The death of a 12-year-old child with congenital long QT syndrome after a physician unknowingly prescribed a medication that prolongs the QT interval and increases the risk of torsades de pointes

You’ve also likely read about recurring fatal errors that continue despite repeated descriptions of these events in ISMP newsletters and other publications and recommendations to prevent these and other repetitive types of errors highlighted in the ISMP Targeted Medication Safety Best Practices for Hospitals. For example, in 2015, ISMP wrote about:

  • Yet another patient, this time a 51-year-old hospitalized man, who died from an anaphylactic reaction largely because EPINEPHrine was not available, and the nurse felt she could not act without an order or protocol to administer the drug
  • Yet another patient, an elderly man, who died after he decided to double his weekly oral methotrexate dose to treat worsening rheumatoid arthritis symptoms, without knowing the consequences of increasing the dose

As you’ve read about these tragic medication errors, you’ve probably felt surprised, saddened, anxious, unsettled, and perhaps even a little angry or frustrated, as we often feel at ISMP when these errors continue to harm patients. These initial gut feelings cause you to feel leery about errors, even if you can’t put your finger on the exact cause of your uneasiness (Weick & Sutcliffe, 2001). Unfortunately, we have a tendency to gloss over these initial gut feelings and treat many errors as inconsequential in our own lives and work (Weick & Sutcliffe, 2001). Thus, the tragic medication errors you hear about may be compelling, but are perhaps felt to be irrelevant to your practice—a sad story, but not something that could happen to you or at your practice site. People tend to “normalize” the errors that have led to tragic events, and subsequently, they have difficulty learning from them.