Children’s Hospital
Children’s Hospital
Amanda M. Scott
National University
HTM 680
Professor Robert Kaye
January 2014
Children’s Hospital
Many unfortunate events have occurred in hospital settings over the years.
Whether it is a near miss, patient safety event, or a sentinel event there is always
something to be learned from the event to improve processes. In the case of Matthew
from Children’s Hospital and Clinics in Minneapolis, MN, this was a medication error
that could have been prevented (Edmonson, Michael, & Tucker, 2007).
Due to multiple factors, Matthew was accidently given an overdose of intravenous
morphine, which resulted in the patient needing to be resuscitated. Thankfully the
resuscitative efforts were successful and Matthew recovered. This became a learning
experience not only for those directly involved but for all in medicine. Throughout the
risk assessment process specific risks were identified and further mitigation strategies
were developed to assist in preventing this event from occurring again.
There are two risks that were quite evident in this event. The first risk that needed
to be addressed is training. Specifically training for the nursing staff and anyone
involved in utilizing and administering medications via an electronic infusion pump. One
of the commendable attributes to this situation is that the nurse on orientation did ask for
help regarding the pump, as he was unsure. Unfortunately it was more of a case of the
blind leading the blind. It was found that many of the nurses on this unit were unfamiliar
with this specific electronic infusion pump because most of their patients do not require
continuous intravenous pain management. Secondly, it was noted that the nurse on
orientation was used as a second verifier prior to starting the infusion pump. This should
never be the case. Anyone on orientation should not be allowed to verify medications.
This should always be between two licensed providers NOT on orientation. At least this
has always been the standard.
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The likelihood of the training risk is medium to high. I believe there is a range
with this risk as it will not always cause or result in harm. In Matthew’s event, it caused
great harm and nearly killed him. Training is such a broad term but is very important to
remain safe.
The other risk noted was the labeling of the actually medication. The nurses
agreed, after the fact, that the labeling was confusing, at least the part of the label that
was shown. The location of the label and the documentation on the label need to be clear
and concise. This also rolls into training as well. The nurses should have clarified the
medication prior to even taking the medication to the bedside.
The likelihood of the labeling risk is high. Granted, not every medication if given
too fast or too much dosage will do harm, the severity of those mediations that can cause
harm make this a high risk. There have been many situations where I have had to clarify
medication dosage with another nurse and even providers. When I worked in the
Intensive Care Unit and on Labor and Delivery we even had cheat sheets for certain
medications that we required during resuscitation. This did not mean that we skipped any
steps or verifying the medication with another provider. This is just an example of how,
even if labeled correctly, some medication dosages can be tricky.
The Children’s Hospital did follow up the even with a collective collaboration of
all involved as well as leaders. This occurred to help understand what caused the event
and how to prevent this from happening again. I truly enjoyed reading that Dr. Robinson
stressed this focused event analysis would be “a blameless environment” (Edmonson,
Michael, & Tucker, 2007). In a culture of safety this is paramount. I have found in
personal experience that this isn’t always the case.
Children’s Hospital
The risk mitigation strategies developed include risk planning and limitation as
well as research and acknowledgement (Stoneburner, Goguen, & Feringa, 2002). Risk
planning would involve future training for staff members. In this case, have all staff
members utilizing the electronic infusion pumps; participate in hands on training with a
super user. Create real life scenarios and have the staff members walk through how to set
up and administer the medication step by step. Provide quarterly or bi-yearly
proficiencies and keep track of all staff members training.
Risk limitation would be to set safe guards or limits on the electronic infusion
pump’s system. For example, morphine could be a preset medication with known
dosages and if the nurse types in a dosage that is not typically prescribed, the pump will
provide a warning. Pumps may also be programmed to provide an alarm setting for
pediatric versus adult dosages for medications. Working on the “front lines”, I have used
pumps that have similar settings. I thought it was a great safety feature especially if it had
the medication I was going to administer. This allowed the pump to save the medication
history as well as provide for safety alerts. I could also, easily look at that pump and
know what exactly was running through it. In the Intensive Care Unit there were many
times were I was responsible for more than eight intravenous drips one just one patient.
It is extremely important to stay organized and have clear concise information.
I particularly like research and acknowledgement as part of the mitigation
process. Utilizing not only past research but also acknowledging current mistakes and
learning from them will only make medicine safer and more efficient. The Children’s
Hospital learned that they required further training regarding the pumps and needed to
Children’s Hospital
change the medication labeling. Acknowledgment of a wrongdoing may be difficult but
it will only allow for growth.
Matthew’s situation is a perfect example of where the five rights would or could
have prevented a harmful situation. The five rights include the right patient, right
medication, right dosage, right route, and right time. If the nurse’s had gone through the
five rights they should have stopped at the right dosage. If they had recognized that the
dosage on the label was difficult to understand they could have clarified with the
pharmacy and provider prior to even bring the medication to the bedside. There has been
many times during my career that I have easily verified a medication three or four times
prior to even stepping foot into the patients room. Also, if the medication was verified
with another nurse who was not on orientation, the dosage on the pump may have been
caught.
In this situation Matthew is a pediatric patient. Medication dosages for pediatrics
are very different from adults. Many of the pediatric medication dosages are based off of
the child’s most recent weight. As we are in the United States we tend to measure weight
in pounds. However, when it comes to medication dosing, the pounds need to be
converted to kilograms. The mediation itself may need to be converted from grams to
milligrams or liters to millimeters. As you can see this requires a lot of math and precise
math at that. This is another reason/example why having two licensed verifiers is
required for safety of the patient. Pediatric patients are typically smaller in weight than
adults are more sensitive to medications, hence why weight dosing is so important.
The medication error that occurred to Matthew is not any single individual’s fault.
Collectively as a team of medicine, all involved had some responsibility. The positive
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perspective is that the individuals involved, the facility, and any other medical facility
can learn from this situation. It takes a team effort to provide safe and effective
medicine. Julie Morath explained it simply, “the health system produces health, but it
also produces harm.” (Edmonson, Michael, & Tucker, 2007). Acknowledging this will
allow for further growth and improvement towards safer care.
Children’s Hospital
References
Edmondson, A., Roberto, M., & Tucker, A.. (2007) "Children's Hospital and Clinics
(A)." Harvard Business School 9(2) 1-25. Harvard Business School. Web. 1
Jan. 2014.
Stoneburner, G., Goguen, A., & Feringa, A.. (2002) "Computer Security." National
Institue of Standards and Technology 30, 1-40.