Incident reporting: Don't shoot the
From the Feb. 26,1997 Issue
Problem: Hospital medication error reporting programs
can be an invaluable tool to evaluate problems in the medication
delivery system. Unfortunately, many hospitals continue to
use error reports as the basis for disciplinary action against
the workers involved.
A nurse recently contacted us because she had made a serious
medication error, and was afraid to report it to her manager.
The nurse was concerned that this would blemish her record
and feared that next time she committed an error she might
be suspended or even fired. Soon after arriving for her 7-3
shift, she changed the tubing on a patient's dual chamber
IV pump which was infusing D5 in 0.45% NS at 100 mL/hr and
heparin solution at 18 mL/hr. On her unit, heparin was always
set as the secondary infusion, but when she rehung the IVs,
she accidentally reversed them. In reprogramming the pump,
the settings were not changed. As a result, the patient received
the heparin at 100 mL/hr - more than a 5-fold overdose. The
nurse realized her mistake an hour later when she returned
to shut off the heparin infusion in order to prepare the patient
for an invasive procedure later on that afternoon.
The nurse wanted to know if the patient could be effected
during the procedure by the overdose of heparin, but because
she was afraid to ask anyone at work, for some reason she
called us. Although it seemed unlikely that the increased
amount of heparin would have an effect several hours later,
we encouraged her to report the error because the physician
might choose to postpone the procedure as a precaution. We
later learned that, because of her fears, she declined to
inform anyone of the incident. Any attempt to address the
systemic factors that cause this type of error were lost (see
ISMP Medication Safety Alert! October 9, 1996).
SAFE PRACTICE RECOMMENDATION:ISMP certainly does not
condone this nurse's decision, but we do understand the mindset
behind it. An important part of an effective risk management
strategy is to foster open communication about errors. In
the long run, patient safety is best served when someone honestly
reports an error and describes contributing factors. If people
do not see any benefits, there is no incentive to report.
If they perceive a danger to themselves by reporting, an atmosphere
of fear may be created, which discourages, rather than encourages,
Think of those who report their errors as the messengers.
They are alerting management to systemic problems that may
again lead to errors if they go unchanged. The time for action
is not after a patient is harmed. So, rather than "shoot
the messenger," managers should seek out the real sources
of the problem by asking if there is anything that could have
been done to prevent the error in the first place, to catch
the error, or to minimize its consequences. Rather than wait
for an error, you want to look at people and systems proactively.
[A, N, P, Q]