1
SDC #1
Harm scenarios used in the survey.
No. Title
1
Medication—
wrong route,
IV
Description
A medication that was ordered to be given subcutaneously was accidently
given intravenously by the nurse. The patient developed new-onset chest
pain, headache, and tachycardia as a result of the error. The patient was
given a full cardiac workup (troponin levels, electrocardiogram) for the
chest pain, medication to treat her headache, and continuous cardiac
monitoring overnight for her tachycardia. All test results were negative and
the patient was discharged home the next day with no further issues.
2
Liver
laceration
A patient was admitted to the hospital for outpatient laparoscopic
abdominal surgery. During surgery, the patient suffered a minor liver
laceration that caused the surgery to be converted from laparoscopic to
open. This event required an overnight hospital stay to monitor for possible
bleeding.
3
Contrast
allergy
A patient with a known allergy to intravenous contrast material was sent
for a stat computed tomographic angiogram to rule out pulmonary
embolism. The nurse was unaware of the doctor’s order to premedicate the
patient with prednisone and diphenhydramine before the scan. The patient
received the intravenous contrast material and immediately suffered
nausea, vomiting, hives, and swelling. Ondansetron and diphenhydramine
were subsequently ordered and administered. Although the scan was
negative and the patient’s symptoms resolved with the medication, the
patient was required to stay overnight in the intensive care unit for
monitoring.
4
Abdominal
site infection
A patient came to the emergency department the day after she was
discharged from the hospital after gastric bypass surgery with complaints
of redness, swelling, and pain around her abdominal incision site. Upon
examination, the patient was found to have an abscess surrounded by
cellulitis. Review of her chart revealed that antibiotics had never been
ordered for or administered to this patient even though they should have
been, according to protocol. A bedside incision and drainage was
immediately performed and the patient was admitted for a week of
intravenous antibiotic therapy.
5
Mislabeled
blood
specimen
Blood was drawn peripherally by the nurse as ordered for basic laboratory
testing. The nurse, however, labeled the specimens with another patient’s
labels and sent them off to the laboratory. The nurse told the doctor of the
possible mix-up. He then cancelled those results and reordered the blood to
be drawn from the correct patient. The nurse disclosed the error to the
patient, who was upset that the blood had to be redrawn.
2
6
Wrong side
surgery
A patient with severe peripheral vascular disease came to the emergency
department with complaints of right lower extremity pain and
discoloration. It was noted upon assessment that the extremity had an
absent pulse; the vascular surgery department was consulted about a
bypass. The patient’s hospital course was complicated by multiple failed
bypass attempts; amputation of the right lower extremity was warranted.
After surgery the next morning, the patient woke up from anesthesia to
find that his left lower extremity had been amputated. The patient was
immediately frantic and unable to be consoled by medical staff.
7
Lumbar drain A patient was being cared for in the surgical intensive care unit after
surgery for a thoracic aortic aneurysm. The patient had a lumbar drain in
place, with strict standing orders that no more than 30 mL of cerebrospinal
fluid should be drained per hour. A float nurse from another ICU, who was
unfamiliar with this protocol, was caring for this patient. The nurse
inadvertently allowed 75 mL of cerebrospinal fluid to drain during the first
hour of her shift. Upon assessment, the patient was complaining of loss of
movement and sensation from the waist down. The nurse notified the
doctor, who immediately identified the problem and clamped the lumbar
drain. Two days later, the patient regained total movement, but some loss
of sensation in her feet remained.
8
Medication— An elderly patient died after the physician prescribed 15 mg of
fatal
methotrexate daily rather than weekly. The patient received 9 doses before
overdose
the error was discovered.
9
Medication— A patient was to receive oral lorazepam every 6 hours. The last dose was
wrong time
taken from the automated dispensing machine at 0300; at 0900, the nurse
looked for the next scheduled dose. Central pharmacy was contacted at
0930. Pharmacy had not refilled the dispenser and the dose was not
available until 1045. The patient received the dose late but no physical or
emotional symptoms were noted or reported by the patient.
10
Sharps
exposure
Following a procedure in the emergency department, the technician
cleaning the room found a bloody scalpel and used syringes with exposed
needles at the bedside. These items had not been properly disposed of and
posed a risk to the technician who was cleaning the room for the next
patient. The technician was not injured.