Summary of cases presented at the six conferences on patient safety and near misses
| Conference theme | Case synopsis | Medical event |
|---|---|---|
| Introduction | Patient in ER receives another patient’s type specific blood(video dramatization) | • Blood not taken off the infuser from previous case |
| • Nursing strike in progress | ||
| • Many temporary staff in the emergency department | ||
| • Charge nurse in the emergency department | ||
| • Trauma suite assumes someone else checked the identity of the blood hanging on the infuser | ||
| • Charge nurse continually interrupted during the case | ||
| Imperfect information | Patient prescribed hypertension medication over the telephone from home after clinic hours to which they had previously had an adverse reaction | • Medical record unavailable |
| • No independent confirmation of high blood pressure | ||
| • Patient did not recall or remind physician of the history of the adverse reaction drug reactions | ||
| • Physician did not ask patient about drug reaction history | ||
| Verbal communication | Patient received injection of Depo-testosterone instead of Depo-Provera | • Nurse received verbal rather than printed orders |
| • Medications had similar names | ||
| • Inexperienced temporary nurse | ||
| • No supervision of temporary nurse | ||
| Information hand off | The resident did not communicate with either the patient or outside physician regarding the abnormal results of the prenatal birth defect screening test | • No formal protocol at clinic for the communication of abnormal results to the patient or outside physician |
| • No formal protocol for the clinic attending physicians to review results of tests ordered by the residents | ||
| • Resident did not bring test result to the attention of the clinic attending physician | ||
| Physician slips | Physician correctly wrote intended dosages for the diabetes medication in the patient’s medical record, but wrote the corresponding prescription for a higher dosage than intended | • The higher dosage was commonly prescribed but wrong, and the lower dose, although correct, was an exception for the usually prescribed doses |
| Residency training and human factors errors | Follow up on an after hours abnormal potassium test (panic value) not appropriate | • Training program culture assumes that residents know how to handle this type of situation |
| • No clear guidelines for residents on how to respond to after hours panic values | ||
| • Patient reported feeling well |