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mother was given the wrong medication, which caused a cardiac
arrest, leading to permanent brain damage. The patient was eventually
placed on life-support and died a few days later.
The hospital began an investigation to determine how the error
occurred and informed the patient's family a few days later that a
medication error was to blame. The hospital initially found a pharma-
cy worker had prepared an IV bag with rocuronium (a paralytic)
instead of fosphenytoin (an anti-seizure medication), which was
ordered. The error and its catastrophic outcome were made even
more complicated thanks to a series of related events.
The investigation found that after initially filling the prescription, a
second pharmacy employee failed to spot the error when she checked
the IV bag and vials. The IV bag was then labeled as containing the
anti-seizure medication and sent to the ER, where it was administered
to the woman.
Adding to the event was that during administration of the drug there
was a fire alarm at the hospital. Per the hospital's protocol, the patient
was left alone and the doors automatically closed to prevent any fire
from spreading. The patient was not checked on until 20 minutes
later, when a nurse found the woman in cardiac and respiratory
arrest.
At first glance, you may want to blame the pharmacy worker who
prepared the incorrect IV infusion. However, in these types of events
it's important to avoid rushing to a conclusion without looking at the
incident from a broader perspective. Looking for the primary cause of
an event limits your ability to identify other contributing factors.
If faced with a medical error, you want to analyze and identify all of
the potential reasons for the problem. Human factors, such as distrac-
tions and fatigue, similar packaging and names, staffing issues, poor
M E D I C A L M A L P R A C T I C E
