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Incident reporting: Don't shoot the messenger!

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, reporting.

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]

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