Table 1

 Summary of cases presented at the six conferences on patient safety and near misses

Conference themeCase synopsisMedical event
IntroductionPatient 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 informationPatient 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 communicationPatient 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 offThe 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 slipsPhysician 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 errorsFollow 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