[two_third]<\/p>\n
On May 15, 2012 the Washington Patient Safety Coalition sponsored its tenth regional conference, and among the outstanding speakers and presentations was a unique session. Chris Jerry and Eric Cropp spoke together about a terrible event that occurred several years ago:\u00a0 Chris\u2019 young daughter died as the result of a medication error for which Eric (as the supervising pharmacist) was held responsible.\u00a0 As a parent, I truly don\u2019t know if I would have been able to reach out to and forgive Eric and to focus on improving safety.\u00a0 I like to think I could, but I\u2019m not sure. Chris says that this is the best way he can honor his daughter: by working to see that this doesn\u2019t happen to anyone else, whether they are patients or providers.<\/p>\n
The presentation and ensuring discussion were very moving, insightful, and thought-provoking.\u00a0 Rather than try to summarize it, I\u2019ll share a personal near miss, as I think it illustrates several of the issues related to error, blame, shame, systems failures, and more.<\/p>\n
I was working my first job as a new graduate, on the night shift (11 p.m. \u2013 7 a.m.) on a general medical floor.\u00a0 This was in 1982 or 1983, so a few of the details are hazy, but the important ones are very clear and sharp.\u00a0 One of my patients had a central line that needed flushing with urokinase.\u00a0 I entered the room late in my shift (about 5 or 6 a.m.) to flush the line.\u00a0 At that time it was a practice norm to keep small multidose vials of things like potassium and heparin at the bedside, to be drawn up on the spot.\u00a0 (This may be hard for younger practitioners to believe, but that was the norm at that time.) I picked up what I thought was the vial of urokinase and drew up the specified amount, cleaned the line, and prepared to inject it into my sleeping patient\u2019s central line.\u00a0 For some reason I decided to take a second look at the vial I had just set down.\u00a0 It was not urokinase.\u00a0 It was potassium chloride. The vials were the same size and shape, with very similar labeling and color.\u00a0 Even now, 30 years later, I break out in a cold sweat and get nauseated when I think how very close I came to killing my patient with a direct injection of potassium chloride, and how thankful I am that something<\/em> made me check again.\u00a0 I never told anyone at the hospital (let alone my patient) what I had done, or almost done.\u00a0 I was mortified, ashamed, and scared to death at what I had almost done \u2013 and there was no one to tell and no system for doing so. It didn\u2019t occur to me to tell my supervisor or any coworkers.<\/p>\n Looking back, there were multiple red flags for many kinds of error to occur:<\/p>\n If there been a system in place at that hospital to report near-misses and safety concerns, this near-miss could have been avoided.\u00a0 Perhaps some other nurse at a later time did<\/em> administer the wrong dose, because I didn\u2019t let others know what had happened.\u00a0 I don\u2019t know, but I hope it never did. While that is a truly terrible possibility, I am heartened by what I hear from my colleagues in our patient safety community about their system improvements.<\/p>\n The fact that I am still disturbed by this near-miss 30 years later also illustrates the importance of another patient safety aspect that\u2019s in evolution: support for providers (often called the Second Victims) involved in incidents.\u00a0 I encourage all of us to continue to improve safety for our patients: removing single or multi-dose vials from the beside was an important step.\u00a0 Let\u2019s also work on support for the Second Victims.<\/p>\n\n