Medication Errors: Submitting Error Forms

Question 1

Patient ID Example?

Answer 1

11111 or N/A

Question 2

Patient Age Example?

Answer 2

68 (just number in years)

Question 3

Patient Gender Example?

Answer 3

Male or Female

Question 4

Patient weight in kg Example?

Answer 4

70 (2.2 kg in 1 lb)

Question 5

Patient Error Category Example?

Answer 5

Category A - No error but circumstances could have lead to an error
Category B-D - Error occurred but no harm (patient may or may not have received medication)
Category E-H - Error occurred and caused harm
Category I - Error occurred and patient died

Question 6

Patient Error Category Example?

Answer 6

Category A - No error but circumstances could have lead to an error
Category B-D - Error occurred but no harm (patient may or may not have received medication)
Category E-H - Error occurred and caused harm
Category I - Error occurred and patient died

Question 7

Patient Event Date Example?

Answer 7

4/1/15

Question 8

Event Time Example?

Answer 8

9:00 AM

Question 9

Setting of initial error example?

Answer 9

?

Question 10

Personnel Involved example?

Answer 10

Nurse

Question 11

Drug strength example?

Answer 11

100 units/mL

Question 12

Frequency example?

Answer 12

Continuous infusion

Question 13

Route of administration example?

Answer 13

IV

Question 14

Status example?

Answer 14

Legend

Question 15

Dosage form example?

Answer 15

IV

Question 16

Packaging example?

Answer 16

IV Solution

Question 17

Error Type example?

Answer 17

Improper dose error, monitoring error

Question 18

Cause of Error example?

Answer 18

Human Factors: Knowledge Deficit

Question 19

Contributing Factors example?

Answer 19

Lack of proper trraining

Question 20

Contributing Factors example?

Answer 20

Lack of proper training

Question 21

Description of event example?

Answer 21

This 68 year old man was to be receiving a heparin infusion for his NSTEMI. The nurse was monitori9ng the heparin drip, according to the protocol and drew the 6 hours aPTT/heparin correlation. She also drew the PT/INR, which typically used to monitor warfarin. Because the aPTT/heparin correlation was taking a while to come back, she adjusted the heparin drip based on the INR. She gave a 2000 unit bolus and increased the drip rate by 100 units per hour. At 2 pm, when she repeated the level, it was greater than 2.2 and she also noticed that the previous level she was waiting on came back at 1.8. One hour later, the patient was unresponsive and a head CT showed a massive hemorrhagic stroke. He was then transferred to the NICU. To avoid errors such as this in the future, in-service education could be provided to emphasize the appropriate lab monitoring for each medication. Additionally, the hospital policy could be adjusted so two providers must sign off (another nurse or the physician) prior to making dose adjustments. I recommend an in-service be completed twice-annually to ensure the staff knows how to use the protocol. Additionally, the policy should be updated so two nurses should sign off before dosage increases. To ensure this is done properly and avoid future errors, the clinical pharmacist on service will be responsible for conducting a medication use evaluation on these heparin forms monthly.