A 55 year old man presented to an ER with fever. Following an assessment the MD ordered an IV antibiotic and an antifungal IV drug- Diflucan . The nurse requested the Diflucan from the pharmacy. A 50ml bottle of Diprivan (sedative hypnotic agent) was sent to the ER erroneously labeled as
“ Diflucan 100mg/ml”. The nurse noted the bottle contained an opaque solution rather than the usual clear plastic bag of Diflucan she was familiar with.
While she was initiating a phone call to the pharmacy for clarification, a MD demanded her immediate assistance.
One potential failure mode includes medications with similar names. The institution can perform a failure modes and effect analysis prior to using the medication. The analysis involves identifying what errors could occur in that process, the significance of the errors and measures to prevent those errors. In the similarly named medications example, the institution may choose to utilize another drug, provide additional labeling alerts or ensure proper storage to prevent potential errors.
COMPLEXITY - A more complex system will have many steps involved which increases the risk of error. Many of the systems or processes involved in patient care have numerous steps. For example the process of administering medications involves multiple steps. Each of these steps presents an opportunity for errors.
VARIABILITY- Systems or processes that involve unpredictable or changing input have a greater failure rate. In health care, patients are unique and require individualization . While the process of administering medications may have universal steps( 8 Rights), there are some steps that are patient dependant such as correct dose range. The more variability present in a system or process the chance for errors is increased .
HUMAN INTERVENTION- While most errors are system failures, human intervention may also play a role. Any system that depends on humans as part of the process has an increased risk for errors. One common misconception is that by telling someone to be more careful errors will be reduced. The reality is that healthcare providers are for the most part very careful and conscientious. One specific problem in healthcare is the over reliance on memory to prevent error. A more effective approach is to design systems or processes that provide prompts or the use of checklists.
HIEARCHICAL CULTURE - An environment that operates under the “Captain of the ship is always correct” or “ I’m in charge do as I say” rule is not conducive to questioning consistencies. If someone is afraid to raise questions there is an increased risk for errors. Individuals must trust that they will not be penalized for questioning inconsistencies.
TIGHT COUPLING -A tight coupled system involves many steps that follow closely and so if an error occurs it can not be detected prior to the next step in the process.