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The road less traveled

From the Augus 21, 2002 issue

Isn't it frustrating when you think you've solved a problem, but it reappears months later? There's a reason for this unsettling sense of déjà vu. Simply put, the action taken was ineffective, even if it seemed to solve the problem temporarily. Then it's back to the drawing board to find a more effective solution. But on this long and sometimes discouraging journey toward solving problems, our initial steps may show results that are partly effective; steps that clearly reduce the risk of error, even if all chance of it happening has not been eliminated. An error report submitted by a hospital illustrates this point well.

Midazolam syrup was used frequently on the hospital's pediatric unit, so bulk bottles of the syrup (2 mg/mL) were stocked in the automated dispensing cabinet. After several calculation errors led to overdoses, the screens on automated dispensing cabinets were redesigned to provide dose warnings. Dose conversion charts also were posted nearby to eliminate the need for calculations. This seemed to work for quite a while, but recently another overdose occurred. A child was to receive 6 mg of midazolam. The nurse had used the conversion chart to determine the correct volume of syrup to administer (3 mL). However, a mental slip caused her to confuse the dose in mg (6) as the volume to be administered. She incorrectly drew up 6 mL of syrup and administered 12 mg of midazolam to the child. Luckily, no harm resulted.

Certainly more could be done to prevent overdoses with midazolam syrup. Unit dose dispensing of midazolam doses from the pharmacy is just one example. But more to the point, this error report clearly typifies where many healthcare providers are today - not at the final destination of error prevention, but on the right road, with frequent pit stops to try out new error reduction strategies. And it's good to be on the right road, heading in the right direction. But as we improve processes and systems, errors are still possible if people are involved. Mental slips and lapses can happen to the most experienced, vigilant, and well-trained clinicians - they are unintended and unpredictable, thus largely unmanageable. As a result, human error should be anticipated and methods to detect errors must be employed to prevent serious harm.

While technological solutions such as computerized prescriber order entry and bar coding systems have great potential to detect human error, manual redundancies such as independent double checks still play an important role in error detection. Studies show that manual redundancies detect about 95% of errors. And while the 5% of errors that get through human detection systems make it unreliable as an error prevention strategy, that's hardly the point if a manual check is the only way to detect an error that could lead to patient harm.

In the end, independent double checks serve two purposes: to hopefully, though not dependably, detect a serious error before it reaches a patient; and just as important, to bring attention to the systems that allow the introduction of human error. Using the example above, if an independent double check had been employed before giving the child midazolam syrup, there was a 95% chance that the error would have been detected. If it did, an equally important step would be to bring the issue back to the table for discussion on how to further reduce the risk of an error or prevent it. This takes error prevention to the next level, rather than relying on an imperfect but necessary manual check system. Likewise, if an independent double check had been employed in the case above, but the error hadn't been noticed until after the child received the overdose, the issue wouldn't be the failed double check. More importantly, the issue still would be how to fix the system so that we can move further along the road toward error prevention. In the end, by taking this more difficult path - the road less
traveled - we will be able to say, "and that has made all the difference."

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