Fibrinolytic Given in Error Due to Multitasking and Distraction

The event

A resident was consulted on two patients and had both patients' charts open in the electronic medical record. One patient warranted administration of an intravenous (IV) fibrinolytic drug. The resident was distracted and inadvertently entered the order for the drug in the wrong patient's medical record.

The pharmacist on the inpatient unit verified the drug order, but the staff nurse questioned whether the IV infusion could be administered on the inpatient unit. The pharmacist contacted the resident on the primary physician team to inquire into the drug's indication; the information gained was logical yet inconclusive. The resident on the primary physician team did not follow up with the consulting resident to clarify the drug's indication. The pharmacist then reviewed the notes from the consulting resident and found sufficient documentation that the drug was warranted. The pharmacist consulted with another pharmacist who indicated the low dose of the ordered drug is commonly ordered and that no additional monitoring was needed. The pharmacist on the inpatient unit relayed this information to the nurse and the IV infusion was started.

The medication error was discovered 13 hours later. The patient did not experience any adverse effects from the drug infusion.

Critical analysis

"Anybody can make this kind of mistake," said Sang Hoon Woo, MD, a hospitalist and a member of the Care Improvement Committee and the Medicine Professional Practice Evaluation Committee. "Doctors are often busy and need to perform multiple tasks at the same time. We need to remember we are more likely to make errors when we are busy, especially this kind of error."

Three lessons can be learned from this incident, Woo said. "First, just as we perform a "time out" immediately prior to a procedure to avoid errors, we need to take time before ordering a medication to confirm a patient's identity and the indication for the medication, particularly for medications with potentially significant side effects such as fibrinolytics, anticoagulants and chemotherapy."

Second, he said, "when a cross-coverage physician receives a call from pharmacy or other staff and does not know the details of a patient's care, the same physician needs to contact the attending physician instead of assuming the patient condition. The cross-coverage physician needs to follow up to make sure the issue is resolved, especially at night. The culture against bothering attendings at night is strong, however patient care is the most important thing."

And, finally, following the same direct approach to communication, "pharmacy should contact the person who wrote the medication order."

Hospital Pharmacy Director Michael Brown, PharmD, agreed. "There are policies and protocol for escalation of clarification of orders. We have taken this incident and discussed it in pharmacy staff meetings, made it a teaching point for all: Question everything—and trust, but verify."

Staying familiar with hospital protocols on medication administration is also crucial. In this incident, neither the pharmacist nor nurse was aware of policies prohibiting administration of IV fibrinolytic on an inpatient unit. Learning policies through Healthstream is valuable, Brown said, "but Healthstream cannot teach experience. I've been in the field for 35 years and I learn something new every day. That's the attitude we try to emphasize here at the hospital—and that every policy we have in some way is rooted in patient safety."

Shared learnings

• Avoid distractions when entering orders into a patient's medical record.
• When in doubt about a physician's order, consult directly with the ordering physician.
• Be knowledgeable about the policies that govern drug administration on certain inpatient units.