Patient Care at Risk: A Case Study in Preventing Medication Errors

Medication errors are among the most serious and preventable threats to patient safety. From prescribing and dispensing to medication preparation, administration, and monitoring, every step of the process presents opportunities for error. While technology and standardized procedures can help reduce risk, healthcare organizations must also account for human factors, communication breakdowns, distractions, and weaknesses in their existing processes.

Preventing medication errors requires more than asking individual healthcare professionals to be vigilant. Effective medication safety depends on creating multiple layers of protection that help identify and stop an error before it reaches the patient. When those safeguards fail, or gaps in several processes align, even a seemingly simple medication mistake can result in serious consequences.

This article examines a tragic medication error involving a newborn infant and explores the broader lessons healthcare organizations can take from the case. Using the Swiss Cheese Model and other principles, we’ll examine common causes of medication errors, high-risk points in the medication administration process, and practical strategies healthcare organizations can use to strengthen medication safety, reduce human error, and protect patients from harm.
 

The Case

A mother arrived at the hospital in spontaneous labor and delivered vaginally. The baby and mother were then moved to a mother-baby floor for continued monitoring. Post-birth testing revealed that the infant’s RPR testing was reactive at 1:2, and the pediatrician ordered an IV penicillin protocol. The mother was given orders by her physician for the injectable medication, Bicillin.

Two days after delivery, the baby was due for its next dose of IV penicillin. Medication was placed in the infusion pump. Fifteen minutes later, the baby was returned to the mother’s room.
An hour later, it was noted that the baby was difficult to rouse, the right-hand IV was no longer flushing, and the infusion was incomplete. As a result, the baby was taken to the nursery. Eventually, a new IV was started on the right foot, and the IV infusion was continued.

Approximately three hours after the infant’s infusion was completed, it was time for the mother’s next dose of Bicillin to be administered. When the nursing staff went to the medication storage cooler, it was discovered that the mother’s medication was missing, and the infant’s penicillin dose remained in the cooler. It became apparent that the mother’s Bicillin was inadvertently given to the infant via the infusion pump.

Within an hour of the discovery, the infant was transported out for a higher level of care. Unfortunately, the Bicillin caused significant damage to the infant’s tissues, resulting in a colostomy, lower limb amputations, and skin debridement. The case was reported immediately following the adverse drug event. It was settled quickly on behalf of the facility.
 

Understanding Why Medication Errors Happen

Medication errors like this rarely result from a single point of failure. In many cases, several contributing factors can come together to create an opportunity for an error to reach the patient. Understanding these contributing factors is an important part of preventing medication errors and strengthening medication safety.

Common causes of medication errors in healthcare today include:

• Patient identification errors: Medications may be selected or administered to the wrong patient when identification processes are inconsistent or incomplete.
• Look-alike or sound-alike medications: Similar names, packaging, labels, or storage locations can increase the risk of selecting the wrong medication.
• Storage issues: Storing medications for different patients or populations together can create opportunities for selection errors.
  Interruptions and distractions: Medication preparation and administration require concentration. Phone calls, alarms, conversations, and competing clinical demands can contribute to mistakes.
• Communication breakdowns: Incomplete orders, unclear instructions, or failures to communicate changes in treatment can contribute to medication administration errors.
• Workload and staffing pressures: High patient volumes, time constraints, and competing priorities can make it more difficult for staff to consistently follow medication safety procedures.
• Technology-related issues: Electronic prescribing, automated dispensing systems, and barcode scanning can reduce risk, but they must be implemented correctly and consistently.
• Failure to follow established processes: Policies and procedures are only effective when staff understand them, have the appropriate training, and consistently follow them.
   

Because these factors can overlap, healthcare organizations should focus on building systems that make errors easier to identify and harder to reach the patient. Medication safety should not depend solely on an individual remembering to catch a mistake. It should be built into the medication-use process through multiple safeguards.
 

How to Reduce Medication Errors

We can only speculate why the nurse delivered the wrong medication to this infant in our case study. Human factors contributed greatly to the poor outcome, as the only thing preventing this error from being made was the human in charge of administering the medication. As human beings, only one thing is certain: we all make mistakes. Unfortunately, this mistake resulted in lifelong harm to an infant.

Dr. Scott Shappell and Dr. Doug Wiegmann developed the Human Factors Analysis and Classification System (HFACS) that describes four categories of latent and active human factor failures that occur and lead to an adverse event. These categories should be incorporated into event investigations to assist in root-cause analysis and identification of potential human factors that may need to be controlled to prevent errors in the future.

Consider these tips while reviewing medication storage and administration processes and policies in your facility:

• Store adult and pediatric medications separately. The mother and infant are two separate patients, so their medications should not be stored together.
• Consider color-coding medication labels specific to pediatric medications.
• Use a process of pulling medications for delivery from an automated, patient-profile-driven system. Medications ordered for a specific patient will only be available for access.
• Use a barcoding and scanning process at the bedside before administration of the medication. Educate and monitor staff for compliance during the use of these scanning systems.
• Standardize the process of patient identification using the name and date of birth in comparison to the identification band and the medication administration record.
• Print and attach warning labels to medication that indicate that they are for injection only or IV infusion only.
• Reduce distractions while preparing medications for administration by using a medication room with a closed door.
• Implement quiet zones for medication preparation areas where the nurse is not interrupted while preparing medications. Encourage reduced noise levels to limit distractions.
• Enforce the Five Rights of Medication Administration that create a framework for medication safety and administration — right medication, right dose, right time, right patient, and right route.

The Swiss Cheese Model 

One useful way to understand medication error prevention is through James Reason's Swiss Cheese Model. The model illustrates how accidents can occur when multiple layers of protection contain weaknesses that happen to align. In healthcare, the goal is to incorporate layers of hard stops along the way using standardized processes and technology to help healthcare workers recognize and resolve the error before it reaches the patient at all.

For medication administration, these layers could involve:

• Accurate prescribing and order verification
• Patient-specific medication dispensing
• Appropriate medication storage
• Clear medication labeling
• Standardized patient identification processes
• Barcode medication administration
• Verification of the Five Rights of Medication Administration
• Independent double checks for medications or situations requiring them
• Appropriate monitoring following medication administration
• Accurate documentation and communication

This approach also changes how organizations investigate medication errors. Rather than asking only, "Who made the mistake?" healthcare leaders should ask, "What allowed the mistake to reach the patient?" A thorough investigation should examine the systems, processes, environment, technology, communication, and human factors surrounding the event. 

This can help organizations identify opportunities to strengthen each layer of protection and reduce the likelihood of a similar event occurring again.
 

Medication Safety Checklist: Questions Healthcare Organizations Should Ask

Regular medication safety audits can help healthcare organizations identify vulnerabilities before they result in patient harm. Leaders can use the following questions as a starting point when reviewing medication storage, preparation, and administration practices.
 

Medication Prescription

• Are medication orders complete, accurate, free of ambiguity, and compliant with organizational policy?
• Are providers using a computerized provider order entry (CPOE) to submit medication orders?
• Are verbal orders used only in emergent or urgent situations?
• Are overrides in the electronic dispensing system minimized and reviewed?
• Are high-alert medications prescribed according to established protocols and safeguards?
• Medication Storage
• Are medications clearly labeled and organized?
• Are adult and pediatric medications appropriately separated?
• Are high-alert and look-alike/sound-alike medications identified and stored appropriately?
• Are expired, discontinued, or recalled medications promptly removed?
• Are medications stored according to manufacturer and organizational requirements?

Medication Preparation

• Is medication preparation performed in an appropriate, designated area?
• Are interruptions and distractions minimized?
• Are medication labels compared with the medication order and administration record?
• Are injectable medications clearly labeled with the appropriate route and warnings?
• Are independent double checks performed when required by policy?
   

Patient Identification

• Is a standardized patient identification process used before medication administration?
• Are staff comparing the patient's identifiers with the medication administration record and identification band?
• Are additional safeguards used when treating patients with similar names or other identification concerns?
   

Medication Administration

• Are the Five Rights consistently incorporated into the medication administration process?
• Is barcode medication administration used consistently when available?
• Are staff trained and observed for compliance with medication safety procedures?
• Are medications administered using the correct route and technique?
   

Monitoring & Documentation

• Are patients monitored appropriately following medication administration?
• Are adverse reactions or unexpected responses promptly recognized and reported?
• Is medication administration documented accurately in the medical record?
• Are medication errors and near misses reported according to organizational policy?
   

Quality Improvement

• Does the organization regularly review medication errors and near misses?
• Are recurring patterns or system vulnerabilities identified?
• Are corrective actions assigned and tracked?
• Are changes to medication safety policies communicated to staff?
• Is staff competency reassessed when a process or technology changes?
• Are trigger tools used for medication audits, such as number of overrides, routine medications, or rescue medication administration?
   

A medication safety audit should help identify where safeguards are working, where they are vulnerable, and where additional layers of protection may be needed. By routinely examining the medication-use process, healthcare organizations can address risks before the "holes" in multiple safety barriers align to harm a patient.

Boost Your Medication Safety with LHA Trust Funds

There’s no doubt that this case was tragic and possibly preventable. It also illustrates the need for healthcare facilities to consistently review medication safety processes and procedures — especially regarding how to reduce the possibility of human error in medication preparation, delivery, and administration to patients.

LHA Trust Funds has gathered a robust collection of medication safety tools and resources from the American Academy of Pediatrics, the American Society of Health-System Pharmacists, the Institute for Safe Medication Practices, and more. Visit our Medication Safety Toolkit to access these resources to promote and reinforce safe medication practices within your organization.

About the Authors

Jamie Lamb
Director of Claims Operations, LHA Trust Funds

Jamie Lamb began her career in claims in 1997. Her experience includes handling multi-line claims in the areas of general liability, medical malpractice, automobile liability, commercial and personal property, excess and umbrella policies, and professional liability. Her experience comes as a former Manager and Litigation Specialist for the American National family of companies. She has been highly involved in the education and training of both internal and external customers her entire career. Ms. Lamb attended both Evangel University in Springfield, Missouri, and Loyola University in New Orleans.

Stacie Jenkins, RN, MSN, CPSO
Vice President of Patient Safety and Risk, LHA Trust Funds

Stacie Jenkins is a registered nurse with a master’s degree in nursing informatics. She has more than 20 years of experience in healthcare, working in patient care and quality/performance improvement positions. As the Vice President of Patient Safety & Risk at LHA Trust Funds, she works closely with hospital administrators, risk managers, and nursing staff to improve patient safety and establish best practices. She conducts on-site assessments and gives presentations designed to help clients address their patient safety risk management challenges.