When errors occur in healthcare, the contemporary approach to patient safety involves evaluation of the root causes of why the error happened, evaluating both system and person factors. Unfortunately, systems are not often designed in a way to set people up for success, to make it easy to do the right thing. According to James Reason (2000, p. 769) “…it is often the best people who make the worst mistakes”. Most don’t have bad intentions, and don’t come to work aiming to make a mistake, and it is for this reason that a fair evaluation of the intentions driving the behaviors resulting in errors should be made. This article is the second in a 2-part series on human error management. It focuses on breaking down human error and differentiating associated behaviors.
Differentiating between human error, at-risk behavior, and reckless behavior
When errors occur, evaluation of the intentions driving the behavior that leads to errors helps to better understand the problem and more effectively develop solutions. There are three categories of behaviors that can lead to risk and patient harm- human error, at-risk and reckless behavior. See Table 1 for a further description.
Table 1:
In the category of human error, three types of events can occur: slip the lapse or fumble. A slip occurs when functioning unconsciously in auto-pilot mode. For example, inadvertently driving to work on a day off due to not paying attention to the task at hand. A lapse occurs when steps in the process are forgotten and thus not completed. Both slips and lapses mostly occur in autopilot mode, when there is an adequate plan in place but a failure occurs in the action steps to carry out the plan (Reason, 2005).
A fumble occurs when an action step is carried in a clumsy fashion. Take, for example, a morning routine in preparing breakfast. Once done, food items must be put away in the refrigerator. Putting the orange juice in the cabinet is an example of a slip. Leaving it on the kitchen counter is a lapse. Knocking it over is a fumble.
It’s also important to differentiate errors from mistakes. Mistakes occur while in a conscious mode, as a result of making incorrect choices. This could be due to inadequate knowledge or experience, not enough information at hand, or using the wrong rules to make a decision.
At-risk behavior is consciously chosen, however, do so because the risk is perceived to be small or justified. Shortcuts and workarounds fall into this category. Immediate rewards such as saving time are often reaped, while patient harm is delayed and unlikely. The norm becomes having a tolerance to these risks. Lastly, reckless behavior is rare – knowing/understanding the risk and disregarding this, acting out of benefit to self versus others.
Case Example
The following case example was highlighted in the Institute for Safe Medication Practices article (2019), discussing the fatal medication error that happened at a large, prestigious hospital by nurse RaDonda Vaught.
A patient was admitted to the neurology intensive care unit (NCU) with a headache and vision field loss in the left eye. Magnetic resonance imaging (MRI) confirmed an intraparenchymal hematoma of the brain, possibly related to a suspected mass behind it. Two days later, the patient’s physician entered an order to transfer the patient to a step-down unit. The patient was then transported to radiology for a full body positron emission tomography (PET) scan. While a radiology technician was explaining the PET scan to the patient, she requested medication to help ease anxiety due to claustrophobia. The patient’s physician was contacted, and he entered two electronic orders. The first order was for VERSED (midazolam) 2 mg intravenously (IV), with instructions, “For PET scan, if first mg insufficient, can give 1-2 additional if needed.” (Note: Versed is no longer available as a brand of midazolam.) The physician then clarified the order by prescribing a one-time dose of Versed 1 mg IV prior to the PET scan. A pharmacist verified the orders within a few minutes.
According to the CMS report, a radiology technician called the patient’s primary nurse to ask if she could send a nurse to administer the IV Versed. The primary nurse asked if a radiology nurse could administer the IV Versed, but the technician said that the nurse was uncomfortable administering this drug and that the patient would need to be monitored. The primary nurse said she would send a nurse to radiology to administer the IV Versed. The technician then administered a radioactive tracer to the patient so the PET scan could be completed in an hour after tracer absorption (ISMP, 2019, paras. 3-4).
As the scenario unfolds, one can easily identify the holes in the swiss cheese. A resource/float nurse was asked to help administer the medication in radiology. She accessed the automated dispensing cabinet (ADC) and under the patient profile, entered in the first few letters VE, in search of the drug name. Versed did not come up because the ADC searched automatically by generic drug names. In order to search by brand names, the setting needed to be manually changed on the screen. Instead of searching by brand name, the nurse went in under the override setting and searched for VE, selecting the first medication that popped up, which happened to be the medication Vecuronium, a neuromuscular blocking agent.
A red box warning populated the screen in response to the override function being used, noting that the medication should be a STAT order. The nurse removed the neuromuscular blocker, thinking it was Versed. No precautions around the use of neuromuscular blocking agents, as high-alert medications, were in place at this hospital.
The resource/float nurse noticed that the medication was in powder form and required reconstitution. She read the reconstitution directions on the back of the label but failed to read the actual drug name on the vial. Of note, versed is only available in a liquid injectable form and the nurse did not recognize that this medication did not come in a powder form requiring reconstitution.
The resource/float nurse arrived at radiology, appropriately verified the patient’s identity, and reconstituted the medication. At this time, the nurse did not notice, or perhaps failed to understand, a warning on the cap that read WARNING: PARALYZING AGENT. An unknown amount of IV vecuronium was subsequently administered to the patient. The nurse then left, having another task to perform in the Emergency Room, and did not monitor the patient’s status including vital signs, respiratory effort, and overall response to the medication.
The hospital’s list of high-alert medications did not include Versed and other moderate sedation medications. In addition, moderate/conscious sedation policies did not address parameters around physical assessment and patient monitoring both throughout drug administration and afterward. The patient was observed by the radiology technician via a camera in a holding room. The patient appeared to be comfortable and resting with their eyes closed. Approximately 30 minutes later, a transporter recognized that the patient was unresponsive. At that point, an emergency response was activated (ISMP, 2019).
It was felt that the medication error caused the patient to arrest and subsequently led to anoxic brain injury. The patient died after life support was withdrawn. Was this error caused by person or system factors? The answer is both.
There were several opportunities for system improvements:
- ADCs that allows for simultaneous searching of both brand and generic names
- Limiting medications that are available via override to emergent/urgent situations only
- Having processes in place in which providers place medication orders and these are verified by the pharmacy prior to removal from ADC
- Use of interactive alerts during medication removal
- Utilizing a second person as a witness for medication overrides
- Warning signs on ADC pockets/drawers/lids for neuromuscular blockers
- Including moderate sedation medications on the high-alert medication list
- Conscious and moderate sedation policies that include assessment and monitoring parameters for patients during and after medication administration
- Implementing barcode scanning verification
- Storing neuromuscular blockers in sealed boxes or rapid sequence intubation kits
Person opportunities include:
- Following the all the 5 rights of medication administration
- Accessing medications via override only in emergent situations
- Reading the vial label to verify the drug name
- Validating the warnings on the vial and ADC
- Monitoring the patient after drug administration (ISMP, 2019)
This was a highly unfortunate event by a nurse who thought she was administering the correct medication, who thought she was doing the right thing and intended to do the right thing. Clearly, there were far more system opportunities than personal ones.
Looking at the behaviors in Table 1, it seems this case would fall into the category of “at-risk behavior” for the opportunities stated above. Violations of policies/procedures or practice standards typically qualify as at-risk behaviors rather than reckless behaviors, because the risk is unknown or wrongly believed to be insignificant or justified. It could also qualify as human error, with the nurse inadvertently picking the wrong medication in the ADC, and overlooking the vial label.
How Do We Do Better?
Building a just culture in which there is a fair assessment of individual behavior and actions based on the behavior, along with system evaluation and changes. From a person’s perspective, an assessment of individual behavior is made in an effort to understand the intentions that led to the behavior causing the error. There is accountability for actions when necessary. As referenced in Table 1, solutions include consoling, coaching, or disciplinary action based on the evaluation of the behaviors. In addition, an assessment of systems opportunities that may have led to the error occurring is also made. This is followed by system improvements to build in better layers of defense and ultimately provide a more effective buffer to patient harm.
References
Institute for Safe Medication Practices (ISMP) (2022, April 07). Criminalization of Human Error and a Guilty Verdict: A Travesty of Justice that Threatens Patient Safety. Retrieved from https://www.ismp.org/resources/criminalization-human-error-and-guilty-verdict-travesty-justice-threatens-patient-safety
Institute for Safe Medication Practices (ISMP) (2019, January 17). Safety Enhancements Every Hospital Must Consider in Wake of Another Tragic Neuromuscular Blocker Event. Retrieved from https://www.ismp.org/resources/safety-enhancements-every-hospital-must-consider-wake-another-tragic-neuromuscular
Reason, J. (2000). Human error: models and management. British Medical Journal, 320, 768-70.
Reason, J. (2005). Safety in the operating theatre – Part 2: Human error and organizational failure. Qual Saf Health Care, 14:56–61
Wachter, R. M. (2008). Understanding patient safety. McGraw Hill.
Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS