Patient Safety: Lessons Learned
Back to Basics: Reading Reduces Medical Errors
By Alexis Victoria Murshed, RN, MBA, CPHRM, CLNC, Director of Patient Safety Operations, Stanford Center for Advancing Patient Safety (CAPS)
The health care industry worldwide has seen an increase in the use of technology for both efficiency and safety. Barcode scanners can help prevent wrong patient, wrong concentration and wrong medication errors from occurring. Although technologies such as these have helped decrease errors, while also increasing efficiency, errors still occur. Technology is only as good as its user and there are still human factors involved in utilizing technology.
In reviewing numerous events and near misses a trend has emerged that is concerning—health care staff are becoming overly reliant on technology. In the absence of technology, many are skipping the essential step of reading. Below are some notable events related to this “failure to read” phenomenon occurring around the nation.
- An anesthesia provider handed a paralytic to a second anesthesia provider, verbalizing the name of the drug. The second provider drew up the drug and administered it without reading the label. When the patient failed to recover, it was found that the wrong paralytic was given. When questioned, the second provider admitted to not reading the label and heard something different than what was verbalized. The patient did recover without sequel, but was frightened when she could clearly hear the command to move and yet was unable to do so. This event could have been prevented by the simple act of reading the label.
- A critical patient required blood products and the pre-transfusion process was completed. When the blood product was received and scanned by the nurse, an alert appeared stating that the blood product had already been given. The nurse failed to read the warning, overrode the alert and administered the blood product. While documenting the post-transfusion vital signs, it was noted the product was given to the wrong patient. The blood should have been given to the second patient in the same room. In this case, there were two opportunities to prevent the error. First, the alert should have been investigated, and second, the nurse should have read the label and compared it to the patient’s wristband. The blood product was platelets and not packed red blood cells, so the patient suffered no ill effects. But this error could have been prevented by reading the label.
- Two residents performing a procedure to stop a wound from bleeding required the use of adhesive remover, but failed to read the flammable warning on the product label. The residents sprayed the aerosolized product on the skin to remove the bandage while a cautery was also being used. The heating element of the cautery ignited the aerosol spray and caught the bed linens on fire. The patient suffered a full thickness burn to her leg but recovered after undergoing procedures to treat the burn.
These are just few cases that illustrate the importance of reading. There will always be distractions in our days, especially in the complex environment of health care, but we must get back to basics to continue providing excellent care to our patients. Reading is one of the essential tasks in preventing medical errors, especially in the presence of adjunct technology.