Independent Double-Checks for Endogenous
Case 1
A physician ordered a heparin infusion with directions to follow a weight-based nomogram for laboratory monitoring and dose adjustments. Later that evening, the nomogram indicated that an intravenous (IV) bolus dose of heparin 1,700 units should be administered based on the patient’s activated partial thromboplastin time (aPTT) level.
The patient’s nurse removed a 10-mL vial of heparin (1,000 units/mL) from an automated dispensing cabinet to prepare the dose. However, she miscalculated the volume that was needed as 17 mL, not 1.7 mL. canadian cialis
The nurse, concerned that she would be using a second vial of heparin to prepare the bolus,quickly asked another nurse to look at her math to make sure that she had not made an error. However, the other nurse did not actually recalculate the volume needed; she thus made the same error when looking over her colleague’s work. The patient received 17,000 units of heparin. A physician’s assistant discovered the error after the patient experienced severe epistaxis.
Case 2
An epidural infusion of fentanyl (2 mcg/ mL) with bupivacaine 0.125% was started for a 62-year-old man who had just undergone a lobectomy for cancer of the lung.The drug was supplied as a premixed product manufactured by Baxter Compass.
Several nights later, a supervisor went to an automated dispensing cabinet to retrieve a replacement bag. However, she accidentally picked up a premixed Compass bag of morphine (1 mg/mL) intended for IV use. The bag was located in the same drawer as the fentanyl/bupivacaine bags. Both bags were packaged in identical brown plastic overwraps to shield the compounded solutions from light.The labels, located on one side of the brown overwraps, were also similar in appearance, and both products were packaged in the same-sized bags (100 mL in a 150mL container).
The supervisor brought the bag to the nursing unit. A second nurse double-checked the product; however, she also failed to notice the mistake, because the bag was packaged in the brown overwrap,as she had come to expect.
The morphine was hung. Several hours later,the patient’s respiratory status began to deteriorate and the epidural infusion was temporarily turned off. Even then, none of the staff members noticed the error. Another nurse, who was documenting the waste after the patient’s epidural catheter was removed, finally discovered the error.
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Although multiple system failures clearly contributed to these errors, in both cases, faulty double-checks allowed the errors to reach the patients.
Why did the double-checks fail? In part, the answer lies with how they were performed and with the differences between endogenous and exogenous errors.
