Archive April 2017 XVIII, No. 4

6 Lessons Our (Near Miss) Medication Error Taught Us

Injecting a patient with local anesthetic instead of contrast dye was a blessing in disguise.

Catherine Dutton, MSN, RN, CNOR; and Diane Betti, MSN, RN, CNOR, CSPDT, ST

local anesthetics in lidded specimen cup HARD STOP After our near miss, we decided to store local anesthetics in lidded specimen cups.

By all appearances, it was another busy vascular case involving numerous insertions of embolectomy catheters and injections of contrast dye. However, the physician assistant who typically worked alongside the surgeon was tied up in another room, so the surgical tech stepped in to help while also performing her regular duties. During the procedure, she turned to draw up contrast dye, but instead filled the syringe with a local anesthetic. Luckily, she realized her error immediately after injecting the patient and notified the surgical team. The anesthesiologist promptly administered lipids, and the patient was unharmed. The tech had followed the hospital's policies for the proper labeling and transfer of medications on the sterile field, but a potentially fatal error still came this close to occurring. Our review of the incident uncovered process improvements we needed to make, but also revealed plenty that went right to prevent patient harm. Here are 6 lessons we learned from the event that we hope you can incorporate into your medication safety efforts.

1. Create a hard stop. Put mechanisms in place to fix a faulty system that creates the possibility of human error. In our case, the surgical tech and the circulating nurse visually and verbally confirmed all medication delivered to the sterile field, including the contrast dye and local anesthetic. During our root cause analysis of the near miss, we decided that our medication labeling and handling policies weren't enough to prevent the surgical tech from drawing up the wrong drug, so we implemented a hard stop for whenever multiple agents are on the sterile field.

We now house local anesthetics in a lidded specimen cup instead of in an open Pyrex cup. The cover acts as a hard stop by creating a deliberate step in the process of drawing up meds; techs now pause for a second or two to consider if a local anesthetic is in fact the agent they want. We added additional specimen cups and lids to our procedure packs, so the surgical team has enough containers to implement the hard stop. We also taught every surgical tech about the new policy, had them sign off on their understanding of it and audited their practice for 6 months to ensure they complied with the new directive.

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