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| 'drink me' |
Most senior health care professionals have a few drugs , their indications, interactions and doses so well embedded In their brains that they do not need to look them up.... But most of them have to turn to the trusted British National Formulary every now and again. More junior staff probably use the BNF more than senior docs, but as the author can attest 'tempus fugit' and having access to a BNF in hard or e-copy is an essential pre-requisite of safe EM.
But can using a BNF actually cause a drug error?...... course it can't.
Can it?
Sadly the ability for the typical human to find the way to err (in medical parlance, 'cock something up') should never be under estimated, even when trying to do the right thing.
1-Route Cause?
A lady in her 40s presented with chest pain. A junior doctor saw her, made a full assessment and thought that her pain was most likely to be gastro-oesphogeal in origin. He wanted to provide her with analgesia, but felt that her pain was not severe enough to warrant intra-venous morphine. He did not wish to provide her with a non-steroidal based drug, as he felt this might worsen her possible dyspepsia.
She had already taken paracetamol at home within six hours.
So he did the right thing, he asked advice.
'Do we have something not as strong as morphine but better than paracetamol?'
A senior nurse suggested codeine.
The junior doc was not familiar with codeine doses.
So he did the right thing, he went and looked it up in the BNF.
The patient had vomited once so the doctor thought he should use a parenteral route
Unfortunately he misread the BNF entry and did not note that codeine can only be given orally or into a muscle.
He prescribed the right dose.............but into a vein not a muscle.
Once prescribed he did the right thing.
He asked a nurse to give the patient the drug.
The junior nurse had heard the conversation between the doctor and the senior nurse and had also seen the junior doctor reading the BNF. She was also unfamiliar with codeine, but she had just seen the doc check the drug in the BNF, it was busy (isn't it always?)
The drug was delivered IV
The patient had an immediate 'rush' and felt 'awful', but this settled within a few minutes. This drug error led to 'no further harm', but that was serendipity not design.
Comments
Despite lots of really good, thoughtful care, a drug error still occurred. Completely well intentioned actions with the best motives resulted in harm. Good God man, they even read the BNF first.....
Someone must be to blame!
When the senior doctors were informed of this error, almost all of them immediately said
'Why do we have codeine solution in the ED I never use it?'
'IM analgesia, in an ED. Why?'
(yes there are exceptions)
An immediate action was to remove all codeine solution vials form the ED within 24 hours.
2-Not all syringes are equal
A renal patient in his 30's came into the ED with symptoms of weakness, lethargy, low blood pressure and slow heart rate.
He said, 'I've had exactly this before when my potassium levels have risen too high'
The junior doctor who saw him established that hyperkalaemia was the indeed the correct diagnosis using a venous blood gas. The doctor then did the right thing, they immediately discussed the patient with a senior saying that they were moving the patient to the resuscitation room for standard hyperkalaemia treatment under cardiac monitoring.
Within 10 minutes the correct diagnosis & treatment plan were established with onward referral to the ward already made. All going well so far!
The junior doctor prescribed an insulin/dextrose infusion in line with the trust guidelines which they looked up on the hospital pharmacy website (they did the right thing). The doctor directed that 10 units of fast acting insulin should be used in the infusion, and did the right thing, by prescribing it all on an IV fluid chart with correct doses volumes and rates. They even wrote out 'ten international units of soluble insulin' in long hand.(see MPS link at end)
Resus room nursing staff drew up the correct volume of 100 units per ml soluble insulin, but did so in a standard 1ml syringe, not an insulin syringe. That volume is, 0.1ml. The doctor caring for the patient thought this volume looked wrong, so did the right thing.......... and checked.
Having searched and read the BNF the doctor recalculated the dose and decided that 1ml was the correct volume to give to achieve 10 units.
Resus was busy (isn't it always?), so the nursing staff had been called away to a sick patient in another bay. The doctor was concerned about their patient so just wanted to 'crack on' with treating him...so despite never having made up an insulin infusion before drew up 1ml of actrapid (100 units) and used that to make the infusion and then filled in the additive label writing that it contained 'ten units of insulin'
The infusion was checked and signed by two nurses, one from the resus room
The patient (unsurprisingly) almost immediately began to exhibit symptoms of hypoglycaemia and the error was equally rapidly noticed and corrected. An immediate explanation and apology was given to the patient and he was told that a formal review of the incident would be undertaken.
Fortunately the patient came to no harm except more frequent BM measurement, which was uncomfortable for the patient, but did him no long term harm, but again this was serendipitous.
Learning Bites
Insulin syringes are specifically designed to avoid dose errors by being graduated in units not millilitres. Only use insulin syringes when drawing up insulin.(MPS on Insulin) & Yorkshire Water Torture
All drug calculations must be checked by two trained health care professionals, as should the doses and volumes put into infusions prior to delivery to the patient
If you haven’t done something before, Resus is unlikely to be the place to start doing it
If you’re not sure about something ask.
If you think someone else has got something wrong it’s OK to ask
A culture of 'its ok to ask' is not a sign of weakness nor 'thickness' but of good safety processes
Commentary
In a system reliant on humans it is impossible to prevent all errors. The best you can do is try to maximise the barriers to error. Which is why I really object to 'aspiring to zero harm'. If you aspire to the impossible, then you will always fall short and in the process mislead the patients and staff.
From the patients perspective 'if harm is entirely avoidable then I should not come to harm. If I have, someone is to blame'
From the HCPs perspective 'if i make a mistake, I will be blamed. I could be disciplined. I could lose my job. I could lose my house. I'm not telling any about this and hoping they don't find out'
So who is to blame?
Well actually no individual is solely to blame. As with most healthcare incidents there was an alignment of system weaknesses that let both patient and the staff involved down. This is frequently described as the Swiss Cheese model.
It is rare that one person does something so enitrely inexpilcable that blame can be laid at their door alone. And anyway blame is such an emotive word. Once an incident has occured you cant undo it, but what you can do is reduce the chances of it re-occuring.
We, the NHS, and EM more widley need to share learning and promote safety by embracing openness and honesty and avoiding blame.
Lets learn not blame
Lets share not hide
Random Link
bonus points available to anyone who knows what this chaps link to the above is
Leonard Thompson
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