Previously I wrote about medication errors in my hospital. I wrote about “just cultures”. This is an atmosphere in a hospital that blames the system rather than the person. Should a medication error occur, and the employee act properly, nothing would happen to the employee.
A few of my hospitals had just culture atmospheres. They were constantly seeking ways to improve technology, procedures, and equipment so that medication errors would not occur.
But it wasn’t only medication errors. All events that jeopardized a patient’s safety, such as those involving falls, wrong surgical sites, clinical alarm mishaps, and other safety-related problems could result in a sentinel event. It was these errors that caused harm or death to the patients. They were called sentinel events because of the immediate need for attention to address these errors.
Establishing A Sentinel Event Committee
Like most hospitals, my hospital had a Sentinel Event Committee. Every Monday the committee would meet. They would require hospital workers who were involved with serious patient safety situations to have their cases reviewed. Some of the cases were severe and actually harmed the patient. Others were considered to be near misses.
A near miss is something that didn’t occur, but if it had, would be considered potentially harmful to the patient. An example of a near miss would be if a person was attempting to cross a street with heavy traffic. In this instance, the person might get hit by a car. This would be considered a near miss. The person DIDN’T get hit by a car but MIGHT have gotten hit by a car if they had tried to cross the street. The installation of a traffic light would prevent this near miss from occurring.
The Sentinel Event Committee would evaluate these actual or potentially harmful cases. They would determine which ones would be deemed “sentinel events”. And which ones would just be corrected.
The Sentinel Event Committee heard a lot of patient safety cases when I was employed at the hospital. What I found interesting was the committee considered each and every case they heard to be a sentinel event. Really? Every case was a sentinel event? Was our hospital lacking in its procedures? Was this a ploy to justify new equipment or additional staffing? Was there some numerical quota of sentinel events that the committee was trying to reach?
I don’t know. But when everything becomes a sentinel event, it sort of loses something in its effectiveness.
Blaming Employees For Sentinel Events
When my pharmacy staff was involved in a sentinel event, we conducted a root cause analysis and action plan. These documents focused on why the sentinel event occurred. They determined what actions would take place to prevent future events from happening.
Many times the individuals who were involved in the sentinel event were required to participate in the root cause analysis and action plan. Quite often, the individuals that caused the sentinel events were blamed (and punished) for their actions. So much for a blameless culture!
I always thought it was wrong to make employees the scapegoat for medical errors and sentinel events. I could think of several situations recently where the patient was harmed or died and afterward the pharmacist or nurse was blamed for the error. It didn’t matter that the hospital had poor systems that lacked proper safeguards. It didn’t matter that the hospital eliminated positions leaving everyone to work with reduced staff. It didn’t matter that employees were expected to work longer hours and double shifts. It was always the employees’ fault. Many times they were suspended, terminated, or brought up on criminal charges.
The hospital claimed they had a just culture. They claimed they created a blameless society when it came to medication errors. I thought blameless cultures should not blame the employees who act properly. But there were a couple of times in my career when I thought the employee was at fault.
Examining A Medication Error And Omitting Everyone Involved
It was the early 1980s and medication orders were written on a physician’s order form. These forms were three-page forms. The physician would have to press hard and write the order on the top page so that the imprint would go through to the other two pages.
The top page of the physician’s order form was pink. That page remained in the chart. The second page contained medication orders. That page was yellow. It was faxed to the pharmacy so that the medication could be filled. The third page was white in color. That order was sent to auxiliary departments (i.e. lab, dietary, X-ray, radiation therapy) to be filled.
In the circumstance involving the medication error…the doctor wrote the order on the physician’s order form. The (yellow) medication order was placed in the nurse’s medication bin. In this particular case, the physician folded the medication order when he placed it in the nurse’s bin.
The nurse transcribed the medication order on the patient’s (nurse’s) record system. The medication record system containing all the medications that the patient was taking was called the “kardex”. The medication order stated to administer “125mg” of a particular medication. The nurse then faxed the medication order to the pharmacy.
After he received the medication order, the pharmacist recorded the medication on the patient’s (medication) profile. It stated that the patient should receive 125mg of a particular medication. The pharmacist sent 125mg to the nurse. The nurse administered 125mg to the patient.
The patient reacted to the medication. It was serious, but the patient quickly recovered.
Upon investigation, it was determined that the patient should have received 25mg, not 125mg, of the medication. The physician claimed that he prescribed 25mg of the medication. However, the problem occurred when the physician placed the order in the nurse’s medication bin. The physician had folded the medication order when he placed it in the nurse’s bin. And in folding it, the crease left a distinct mark on the yellow page. Unfortunately, the line appeared next to the 25mg dose, making it appear to be a 125mg dose.
Both the nurse and the pharmacist interpreted the order to be 125mg. Therefore the patient received a 125mg dose.
This was clearly a medication error. The Sentinel Event Committee ruled it to be a sentinel event. Even though the hospital had a just culture society, both the nurse and the pharmacist were held accountable for their actions.
The physician was not held accountable for his actions. In fact, the physician was not even mentioned in the final analysis or any of the subsequent action plans.
Again, I am not an advocate of blaming employees for medication errors, especially when a facility claims to have a blameless society. But to hold the nurse and the pharmacist accountable, and not the physician, is inexcusable. Especially after I found out why the physician was not held accountable.
A doctor was a special commodity in the 1980s. A doctor could do no wrong— a doctor always got want he wanted. Many times, I remember trying to enforce rules which put me at odds with a doctor. In these cases, it was only a matter of time before I received a call from the hospital’s Chief of Medical Affairs (CMA). As a result, the CMA told me to do whatever the doctor wanted.
I always suspected that this preconceived notion of “the doctor is always right” came about for one of two reasons. 1) That a doctor’s image puts him on a pedestal above everybody else. 2) That there was a fear that the doctor would transfer all his patients to another hospital if he didn’t get his way. This would result in a very costly problem for the hospital.
Regardless, the doctor was not mentioned in the medical error analysis because the Sentinel Error Committee didn’t want to upset him.
Understanding A New Pharmacist’s Thought Process
I had hired a new pharmacist. He worked in the hospital pharmacy for two months. He was very knowledgeable and very well-liked.
On that particular day, his assignment was to check IV solutions. The IVs were prepared and delivered 24 hours in advance. Thus all the IV solutions were for the next day’s use by the patient. Both the label and the product had to match the order before the product. was sent upstairs to the nursing unit for the patient. My pharmacy batched our IV solutions according to the nursing unit. Therefore, we prepared, checked, and delivered each nursing unit separately before proceeding to the next nursing unit.
After three hours, the pharmacist completed his assignment. He had checked the IV solutions for the entire hospital. The IVs had all been delivered. The pharmacist came to see me in my office.
“I wanted to let you know,” he said, “ that while I was checking the IVs that something didn’t seem right.
I was momentarily stunned. I spoke, “Do you remember what it was?”
“No, but something was definitely wrong when I was checking the IV solutions.”
“When did you realize this?” I asked.
He continued, “About three hours ago, when I was checking the second batch of IVs.”
“And what did you do?”
“Nothing,” he replied, “I just continued checking IVs”
“Did you tell anyone?”
“Did you ask for help?” I asked, “Perhaps another set of eyes to see something that you might have missed?”
“No,” he said.
“So let me get this straight,” I said, “You felt something was wrong. But instead of stopping and trying to determine what was wrong— you continued checking all the IVs solutions?”
“Yes,” he said and left my office.
I paused briefly then I left my office. I obtained the help of three pharmacy technicians. The IV solutions weren’t going to be used until the following day. I asked the three pharmacy technicians to divide up the hospital. Then I requested that they bring back all the IV solutions that were checked by the new pharmacist.
The IV solutions would have to be thoroughly examined, as well as checked again, before being re-delivered to the nursing units. I decided to get a different pharmacist involved— not the new pharmacist— to do the checking.
It took an additional three hours to obtain and recheck the IV solutions. We found nothing wrong with the IV solutions or their labeling. In addition, we found nothing that we thought would compromise the integrity of the final product. Once again, the pharmacy delivered the IV solution to the various nursing units. This was the easy part.
The hard part was what to do with the new pharmacist. As I previously stated, I’m not an advocate of punishing any employee who makes a medication error or a near-miss (potential) medication error. But I was having trouble wrapping my head around the new pharmacist’s actions. Or his non-existent ones. Imagine— A person does something wrong or thinks something is wrong and does absolutely nothing! Unthinkable!
I call it my “coffee pot analogy.” A person is reheating a pot of coffee on their stove. They leave the house and drive about a block away. Then they can’t remember if they turned off the burner or if they accidentally left the flame on under the coffee pot.
What they do next is a true indicator of a person’s thought process. If a person thought that they left the stove’s burner on, I would expect the following. The person should drive back to their house and check whether or not they actually left the flame on under the coffee pot.
The problem occurs with the person who doesn’t go back to check the burner. To me, this is a very illogical concept for me to grasp. I can’t understand why a person wouldn’t check, recheck, or stop the process if they had doubts. To me, not checking, could result in a very dangerous situation.
I cannot have any individual working in my pharmacy, whose actions (or lack thereof) put the patient’s well-being at risk. I needed to terminate the new pharmacist.
Daniel Shifrin, R.P., M.S. is a recently retired pharmacist who enjoys sharing his insights about hospital pharmacy. He is proud to own one of the largest collections of Pharmacy Stamp First Day Covers.