Do you see what I see?

Everybody likes a good story, and I hope you'll enjoy one about a near-miss medication misadventure as the celebration of nurses and nursing sensibilities continues during Nurses Week 2009. I like this one because it shows that responsive nursing care remains vitally important to achieving safe and accurate medication use. No HIPAA violations will occur here, because this is my story.

I hope you'll be able to see what I see! And if you like reading this story and analyzing the case, ISMP's Nurse Advise-ERR, a free electronic newsletter, can arrive in your e-mail inbox, giving you access to more error reports and ways to reduce risk. Your free subscription can be activated by registering here.

Several years ago I sought care in my local ER for unrelenting chest pain of about 3 days duration and was diagnosed with bilateral pulmonary emboli. (I would strongly discourage others from waiting for three days to have chest pain evaluated, but in keeping with today's theme, I'll just say that hindsight is 20/20.)

In any event, I was fortunate to have had slow-onset pulmonary micro-emboli, the kind that tend to resolve with anti-coagulation, leaving sufferers in good shape on the back side. So from Sunday evening until Friday morning, I became the lowest maintenance inpatient on a busy medical-surgical unit: I had IV access for about 24 hours, received sub-cutaneous enoxaparin (Lovenox) each day, had daily labs and took a warfarin tablet each evening. The hospital had electronic medication administration records (MARs) and bedside bar-code scanning matched me to my electronic MAR and to the medications ordered and dispensed for me.

You should also know that as a L&D nurse, my knowledge of warfarin therapy was relatively limited. By Day 2, I figured out that I was unlikely to die as result of this particular embolitic event (assuming the pulmonologist's statistics were to be believed). And, once the chest pain resolved, I spent most of the week connected to the hospital's wifi catching up on homework. (Being midway through a master's degree, I took survival of an embolitic event as a sure sign that I should finish school.)

Warfarin teaching came to me by way of the nursing staff. I understood the "go home" INR number to be 2 and was pleased on Thursday morning to know that my number was 1.8, close enough to therapeutic that one more pill and one more night in the hospital would likely buy me discharge home.

On Thursday evening, the nurse caring for me--and the computer work station and med cart she pushed--arrived as expected. My armband was scanned, the med was scanned. "Tonight," she said brightly, "You're going to get 2 pills instead of one." "Really?" I said. "Yes," she replied, "one 10 mg and one 7.5 mg."

I reflected. Something about the cheerful announcement made my hard-drive blink. (My personal hard-drive, not the one with my homework flickering on the screen.) But I had no concrete facts at hand. Having been thankful to survive the scary ordeal, I had been a relatively passive patient up until this point. In fact, I didn't even know what my daily dose of warfarin had been.

So I said, "I don't know much about anti-coagulation, but I have a question. Do you usually give someone whose INR is almost therapeutic a big dose of warfarin to push them farther into the range?" My nurse paused. "No," she said. "Do you mind checking?" I asked. "No, I don't mind. No problem. Glad to do that."

When she returned, she told me, "You doctor wants you to have just one: the 7.5 mg tablet," ending my close call with a warfarin overdose.

Professionals who work in a complex system, especially one that crosses disciplines, can usually see risk points (and opportunities for improvement) in their own sphere of influence.




When complex systems of care are analyzed, those closest to the patient are said to be at the "sharp-end." So if you're a nurse or other provider who touches patients, you're there. And when an error occurs, what went wrong at the sharp-end is relatively easy to uncover.

How to prevent reocurrence is more important than who made the biggest mistake. So I encourage you to look at the big picture, focusing on processes, not people. Here are 4 factors that set this error in motion and allowed it to nearly reach me.

1. My physician wrote an ambiguous order. The daily dose of warfarin 10 mg I had been receiving was not discontinued when the prescriber wrote the 7.5 mg dose on Thursday morning. Clear communication of dose, especially when titrating doses of high alert medications like warfarin, is essential. A process for doing this should be meticulously defined and used.


2. My current INR was not available to the pharmacist. Warfarin is titrated based on a patient's therapeutic response (genetic differences influence the way the drug performs and a multitude of other variables make its therapeutic window maddeningly tight). Absent current INRs, pharmacists cannot perform meaningful dose-checking, a vital part of pharmacy practice.


3. A "high dose" alert in the pharmacy computer system was absent or over-ridden. While 17.5 mg of warfarin is a conceivable dose, it's not a typical dose, especially for a new warfarin user who had shown a predictable response to therapy during the initial days of therapy. Alerts in commercial software programs call attention to orders with unusual doses, enabling the pharmacist to review, and when necessary, intervene before a wrong-dose error reaches the patient.


4. My nurse lacked knowledge of the drug dose & how INR values informed the dose. Warfarin is a high alert drug. On a busy medical-surgical unit, validation of knowledge for high alert drugs should be part of initial competency validation. Additionally, readily available drug resources should be available to front line nurses.

Here are 2 factors that saved me from the overdose:

1. Something didn't make sense to me, so I questioned the plan of care. My clinical condition was such that I could self-advocate, and I did.

2. My nurse did not see herself or the system as infallible. When faced with the possibility that something could be amiss, she double-checked. It's important to realize that I likely would have backed down if the nurse had not been so willingly to call the doctor and double check the order.
A shorter version of the story looks like this:





As I've told this story over the years, most people identify the nurse's knowledge deficit as the primary cause of the near-miss. Her knowledge deficit is a disturbing risk point, but, in my mind, no more so than the events that allowed the erroneous dose to be ordered, entered on the MAR, and brought to my bedside. Should the doctor have been able to communicate an unambiguous dose? Yes. Should the pharmacist have recognized an atypical dose and intervened before dispensing it? Yes. Should the nurse have had better knowledge about warfarin dosing? Yes.

Blaming any one person for the hole in their slice of the cheese is futile. System solutions, like "warfarin order strategies that prevent ambiguous doses from reaching an electronic MAR" and "validating nursing knowledge of high alert drugs during initial competency validation," make each hole smaller. Closing any hole works. Closing them upstream works best.

The last thing I'd encourage you to see is that while I may have saved myself, but I couldn't have done it without my nurse! Thanks to all of you, and happy Nurses Week!

Risk points across the medication use system

Recently, Nurse Ausmed shared a great post about an intervention that lessened the likelihood of an IV medication error occuring in a pediatric patient. Her take-away lesson was "simplify, simplify," a core principle in safe medication practices.

Earlier this week, I wrote that Nurse Ausmed's online case study would lend itself to a basic excercise in identifying the latent (or upstream) conditions that often lead to error on the front line. Links to ideas about modeling human error (developed by James Reason) and some online pediatric medication safety resources were provided.

Here are my initial thoughts:

To answer the question, "Could the error-prone condition be identified and the potential for patient harm lessened before it reached the front line?" start by considering what the medication use system looks like:

The roles and responsibilities of professionals ("who does what, when, and how") may vary according to practice setting and applicable professional standards of care. Irrespective of setting, however, prescribing, transcribing, dispensing, administering, and monitoring are the units, or nodes, that make up the medication use system.

It's important to pause for a moment and take this in. As individuals, we typically focus on the portion of the system where our own professional duties lie, rather the system as a whole, making it difficult to see upstream opportunities.

Now consider the problem of errors in the medication use system:

Errors may originate at any point in the process. In the slide below, the red arrow illustrates how an error that began in the prescribing phase is not picked up, moving through all downstream defenses to reach the patient.

Seminal medication safety research shows the likelihood of catching (and correcting) an error increases the further upstream the error originates. This makes sense since an error in the prescriber's order has the potential to be picked up by the person who dispenses the drug, the person who administers the drug, or the patient. This is why processes like independent double checks and automated clinical decision support are valuable: they make errors and error-prone conditions visible before they reach the patient.

Unfortunately, errors that originate in the administration phase are highly unlikely to be picked up before they reach the patient. This is why processes at the point of administration should be as simple, standard, accurate, and dependable as feasible. (I think of clinicians who administer medications and the processes they use as I would a flight crew: it's probably not a good idea to expect problems to be solved at 35,000 feet that could have reasonably been resolved on the ground or to use patchy processes to accomplish high-stakes, in-flight tasks.)

Later next week, I'll come back to this topic, using clinical information Nurse Ausmed shared to help identify strategies for preventing IV medication errors in peds that are on the high end of the risk reduction hierarchy. I'd hope you'll share the risk-reduction strategies you use when you care for pediatric patients.

Stay safe and come back soon! I've been thinking about something I heard Paula Poundstone say last week, and the next time you check in, you need to be ready to laugh!

A Belief Born of Despair

I've been advocating for solutions to medical error that extend beyond what individuals can do (or can reasonably be held accountable for doing) for a long, long time. In the language of cognitive psychology, this means I ascribe to a system approach for modeling and managing human error.

My belief in system approaches did not arise as a result of study, reflection, or facilitated learning, but came in the aftermath of care my son received in a state-of-the-art children's hospital in 1992. Born with a serious, but fixable digestive problem, my son--and our family--logged more than half of the first year of his life in the hospital.

I've long since forgotten the litany of things that went wrong that year (although equipment malfunction, wound dehiscence, breastmilk mix-ups, tubes that stayed in too long and tubes that came out before their time return to the forefront of my mind after a cursory search of the blessedly faltering "hard drive" where I store these memories). But I have no trouble recalling an evening when I sat in a rocking chair beside my son's crib, meeting with the institution's risk manager who had been called in from home in the aftermath of yet another inexplicable error. "Can you just tell me," I asked in despair, "why the team of seemingly reasonable human beings you represent are so patently unable to render care that does not--in some way, shape, or form--harm my child?"

She could not.

But others have been able to, and over time, I've found solace in some unexpected places. I'm sharing a link to Human error: models and management, a 2000 commentary by James Reason that appeared in the British Medical Journal. This work remains the de facto starting point for anyone interested in the science of reducing human error.

The process of resolving feelings about what happened in the aftermath of my son's difficult start was complex, and I'm sharing just a part of that journey. It's telling that Reason's words--written years after my son's birth--resonated with me, helping to express what I intuitively knew. I hope they will be helpful to you.

I was first able to give up the idea that "bad" (think: careless, stupid, lazy, inconsiderate, incompetent) people were responsible for all that went wrong by considering the problem logically: it was statistically unlikely that our family would have had the bad luck to bump into a disproportionate number of mal-equipped, mal-intended, or simply "off-their-game" individuals with a frequency that could account for the host of significant mishaps that befell us. This analysis may not come to your mind if you seek care once in awhile and have an unsatisfactory encounter or uncover a near-miss. But when you get a data set like the one I had in 1992, you come to realize that some norms, like poor penmanship and ambiguous orders, breed the predictable mishaps that follow.

In my son's case, I ultimately concluded that given the variables of "inpatient days logged" and "complexity of care," he probably experienced the same number of adverse events that anyone else in his situation did. Seeing our misfortunes as a series of unacceptable, but common, outcomes helped me get rid of the feeling that my family was being trailed by some dark cloud of bad juju.

The memory of thoughtful words and genuine acts of kindness also helped dispel the notion that errors in my son's care arose largely because of uncaring or negligent people. In our darkest days, following a leak in my son's newly repaired esophagus, the surgeon shared that he prayed for Luke and for our family, expressing his hope for healing, comfort, and restoration of our family life. The rotating resident brigade, whom I unkindly referred to as the "sneakered sycophants," nevertheless tagged my son with some endearing nicknames, a few that we still use today. One of Luke's home care nurses became a godmother. I share the healing power of these moments, not because I think that intending to do the right thing and actually doing something right are the same. They're not. But these moments helped me see that what was lacking in the care my son received simply couldn't be explained by factors under the control of one individual.

I hope you'll return to this discussion ready to explore more about what turns intention into outcomes, what heals without first hurting. Let me leave you with something that always make me smile: