Medication Errors

Near Misses
Reportable or Ignorable Mistakes
Lycia L. Harris
Jacksonville State University
November 15, 2012

According to Lord Denning, an English Judge

referenced in David Marx, A Just Culture, There
are activities in which the degree of professional
skill which must be required is so high, and the
potential consequences of the smallest departure
from that high standard are so serious, that one
failure to perform in accordance with those
standards is enough to justify dismissal.

Human Beings are not perfect.

Mistakes will and do happen.
Unfortunately, mistakes happen in health care.
Although it is not the correct thing to do, not all
near misses are reported.
The idea of a punitive culture has resulted in under
reported medical near misses and errors.

The Situation

Nurse Pat has worked for 5 days in a row.

Each day, Nurse Pat has had the same patients in rooms 345-350..
Nurse Pat received report earlier in the week that all of her pateins would be
admitted at least 7- 10 days.
Nurse Pat is confident that she is familiar with her patients and no longer relies
on the e-mar and patient identifiers as much because she feels she knows her
patients.
Due to improved medical condition, the patient in 347 is discharged and a new
patient, much resembling the former patient is admitted.
Both the discharged patient and the newly admitted patient were prescribed the
same medication, but the discharged patient was receiving a lower dose than
the newly admitted patient.
Nurse Pat, though she received report, forgot that there was a new patient in
347 because her routine was to get out of report and begin her work as soon as
possible.
Nurse Pat, in a rush, begins the dose of medication for the discharged patient on
the new patient. As she hits infuse on the pump, she notices the label and
name. Nurse Pat realizes her mistake. She quickly takes down the medicine,
discards the tubing and goes to the med room to get the correct dosage.

Failure Modules and Effects Analysis

(FMEA) Tool

The Failure Modules and Effects Analysis Tool(FMEA) is a method

developed by the Institute for Healthcare Improvement that uses a
design that systematical evaluates care processes by trying to
identify how and when a certain process may fail. FMEA looks for
ways to look at how the failure has an impact on those involves and
looks for ways to pin point where the failure occurred to check and
see if the current system in use needs to be changed.
The goal of the FMEA is to find the potential failures, identify them
and fix them before a failure occurs, not after.

FMEA Looks at the following:

The steps in the process.

Failure modules (what other things could have happened).
Failure causes( what would have prevented the error).
Failure effects ( what would be the result of each failure).

The Just Culture Problem Statement

Though and error almost occurred, Nurse Pat, never reported
the occurrence, to administrators nor to the patient. She felt, because
she stopped the medicine before it actually began to infuse, no harm
was rendered to the patient.
The health system that Nurse Pat worked for did have an
accountability system that supported safety. The system required the
nurse to use more than one patient identifier prior to administering
meds. Also, the nurse was suppose to take the medical record into the
room and compare it to the patients arm band before administering the
med. Also, all errors and near misses were to be reported via a tool
called a patient safety report, which Nurse Pat failed to fill out. Failure
to do this was an issue dealing with Nurse Pats personal integrity . The
health system said it had a non punitive culture, however Nurse Pat
knew that was not the case. Nurse Pat was afraid of reprimand.

The Just Culture Model Focuses on Three Duties balanced against

Organizational and Individual Values

The duty to avoid causing unjustified risk or harm

The duty to produce an outcome
The duty to follow a procedural rule
Organizational and individual values include:
Safety
Cost
Effectiveness
Dignity

The rules were in place by the organization. The employee just did not
follow protocol. FMEA can not be used, because this incident was
never reported.

The Second Victim

Nurse Pat was the second victim because the organization that she
worked for created and environment of blame, to which she was
afraid that being honest would cause her to loose her job or be
suspended. Also, if the organization found out this near miss
occurred and was not reported, even more consequences would
follow.
In a Just Culture, one person is not blamed, but the system as a
whole is evaluated to prevent these kind of errors from occurring.
As a nurse manager, this writer would stress the importance of
integrity as it pertained to patient care and the importance of filling
out proper reports so events like this could be followed and new
methods developed.

References:
Institute for Healthcare
Improvement(2010). Clinical teaching
strategies in nursing (3rd edition) . New
York: Springer.
Marx,D. (2007). Patient Safety and the
Just Culture. Retrieved from
Http://www.health.state.ny.us/professional
patients/patient_safety

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