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Medication Errors

Oops, Sorry, Wrong Patient!

A Patient Verification Process is Needed Everywhere, Not Just at the Bedside
Matthew Grissinger RPh, FASCP

Problem: When you think of “wrong patient” medication errors in inpatient settings, the most common scenario that comes to mind is a nurse walking into a patient’s room and administering medications intended for one patient to another patient—often a roommate. Perhaps the patient had switched hospital beds with his roommate to be closer to the window, or he was sitting on the edge of his roommate’s empty bed. Maybe the nurse had verified the patient’s identity during initial drug administration but failed to check it again during subsequent administrations that day.1 Or the process of verifying the patient’s identity was interrupted by a visitor asking a question, and the nurse simply forgot to complete the verification process. In any case, one fundamental cause of these errors is a flawed or absent patient identification process.

However, “wrong patient” medication errors can occur for a variety of reasons at any point in the patient encounter or during any phase of the medication-use process. Examples of hazards, near misses, and actual “wrong patient” errors follow. Fictitious names are provided when necessary to convey the basis of the error.

Prescribing

Order entry error. A dehydrated lung cancer patient was admitted to the emergency department for intravenous (IV) hydration. Another patient from a motor vehicle accident (MVA) was awaiting intubation and transfer to a local trauma center. The same physician was caring for both patients. The physician gave verbal orders for vecuronium and midazolam for the MVA patient, but he inadvertently entered the medication orders electronically into the cancer patient’s record. The nurse caring for the cancer patient went on break, and a covering nurse administered the paralytic and sedative to the cancer patient even though he was not intubated. The patient experienced a respiratory arrest and died.

Reliance on wrong patient data. A physician prescribed medications for a new patient that were based on a medication list in the history and physical of the patient’s sister. A pharmacist discovered the error during medication reconciliation.

Transcription

Mistranscribed telephone order. A nurse accepted a telephone order for morphine 2 mg IV but transcribed the order onto the wrong patient’s record. The order was faxed to the pharmacy and entered as an active order on the wrong patient’s electronic medication administration record (eMAR). The wrong patient, who was already receiving fentanyl, was given the morphine, which caused significant respiratory depression. A rapid response team was called and naloxone was administered.

Intermingled patient labels. When a consulting physician arrived on a unit to follow up with a known patient, he learned that the patient and chart were both in radiology. The physician wrote several orders on a blank order form and asked the unit secretary to add a patient label. The labels for all active patients were kept together in a single file folder. The unit secretary located labels for the correct patient but accidentally removed a label from another patient’s supplies that were right behind the correct labels. The incorrect label was affixed to the order form. The error was captured before reaching the wrong patient.

Dispensing

Data entry errors. To enter an order for a patient named Franklin Hope, a pharmacist tried to access the profile using the patient’s identification number. However, the number was poorly visible on the order form imprint, and the profile could not be located. He then entered the patient’s name, Franklin Hope, and a profile appeared on the screen. While entering the order, the pharmacist happened to notice that the patient was female, not male. He soon realized that he had been entering the order into Hope Franklin’s profile, not Franklin Hope’s profile!

Coupled drug delivery. An oncology patient received another patient’s IV chemotherapy despite patient verification by two nurses before administration. Typically, the pharmacy dispensed each patient’s chemotherapy inside a labeled ziplock bag. In this case, the pharmacy sent chemotherapy for two patients inside the same ziplock bag. When the contents of the bag were removed, the nurses discovered there were chemotherapy bags for two patients. They verified the first patient and the chemotherapy for that patient, but the nurse administering the chemotherapy accidentally picked up the other patient’s chemotherapy bag and administered it to the first patient.

Administration

Reliance on verbal affirmation of name. A nurse entered the waiting area of an oncologist’s office and called for “Mrs. Jackson” to come back to the treatment room for her chemotherapy.1 The nurse carefully checked the chemotherapy orders against the medical record the receptionist had handed her. Verifying only that the patient was Mrs. Jackson, the nurse prepared and administered the chemotherapy. Several hours later, another patient named “Mrs. Jackson” arrived for chemotherapy, and the nurse realized she had administered this patient’s chemotherapy to the prior patient named “Mrs. Jackson.”

ADC overrides entered into eMARs. In two instances, the wrong patient was selected from a patient list on the screen of an automated dispensing cabinet (ADC) in a cardiac catheterization (cath) lab. The ADC allowed access to all patients in the hospital. This ADC could be configured to limit access to patients on up to six units. However, the cath lab needed access to patients in more than six units, so it was configured to allow access to all hospitalized patients. When withdrawing medications from the ADC in the cath lab, the search for the correct patient was typically narrowed by entering the first part of the patient’s account number or last name, and then picking the correct name from the list that appeared on the screen. In the two events, nurses incorrectly picked the names of infants in the NICU instead of similarly named adult patients who were scheduled for cardiac catheterizations. When the medications were removed from the ADC under the infants’ names, it created an override that populated the drugs on the infants’ eMARs. Fortunately, the erroneous entries in the eMARs were noticed before the infants received the drugs prescribed for the adult cardiac cath patients.

Mixing up MARs. The medication administration records (MARs) for two infants were mixed up, resulting in the administration of palivizumab (Synagis, AstraZeneca), used to protect infants and young children from respiratory syncytial virus, to the wrong child. The infants were side by side in isolettes, and both MARs were on the counter between the two isolettes. Coincidentally, both infants had the same first name along with very similar hospital identification numbers. The nurse failed to notice that she was referring to the wrong MAR and administered a dose of palivizumab to the wrong infant.

Monitoring

Mixing up monitoring results. A physician prescribed diltiazem (Cardizem, Valeant Pharmaceuticals) 20 mg IV followed by 30 mg orally for a patient in bed A after a telemetry unit nurse called to report that his cardiac monitor showed atrial fibrillation and flutter with a heart rate of 140. When the patient exhibited no improvement after receiving the drug, the nurse called the physician again and received an order to administer 150 mg of amiodarone IV push followed by a 60-mg per hour infusion. A short time later, the nurse realized that the rhythm she was viewing on the monitor at the nurse’s station was for the patient in bed B. The names of the patients in bed A and bed B had been mixed up and posted on the wrong channel of the central monitoring unit.

Safe Practice Recommendations: First introduced in 2003, The Joint Commission National Patient Safety Goal 1 aims to improve the accuracy of patient identification. Today, the goal requires health care practitioners to use at least two patient identifiers (not the patient’s room number or location) when providing care, treatment, and services. The intent is twofold: 1) to reliably identify the individual as the person for whom the service or treatment is intended, and 2) to match the service or treatment to that individual.

Thus, patient verification using two identifiers should be accomplished with all patient-associated tasks in the medication-use process when:

  • Physicians prescribe medications;
  • Pharmacists and technicians enter/verify orders and dispense medications;
  • Unit secretaries, nurses, and other authorized staff transcribe medication orders;
  • Nurses and other qualified health care providers administer medications;
  • Health care workers set up, obtain, receive, give, document, and/or file diagnostic test results (which are often relied upon for medication prescribing);
  • Health care practitioners participate in other critical processes.
Nurses should have the patient’s MAR or eMAR at the bedside for verification of two unique identifiers. Pharmacists and pharmacy technicians who enter orders into the pharmacy computer should select the patient profile using the patient’s medical record number (never the room number) or by scanning the barcode on the patient’s label on an order set, and then confirm the patient’s name and number on the screen by comparing them to the name and number on the orders; unit secretaries and nurses should compare patient information on the order form and MAR when transcribing orders. However, ensuring that this information is available to physicians in a way that allows comparison of the identifiers for verification presents a challenge unless computerized prescriber order entry (CPOE) systems are in use.

CPOE systems can be designed so that, once logged on, the physician can select the name from a list of patients assigned to him instead of a much larger list of all patients. In the ambulatory setting, a comparable list would be the schedule of patients who are to be seen that day. Enhancing the font used for the patient’s name on the screen also can improve accurate order entry (for pharmacists, too). Some systems can also alert staff to similar names in the registry and require a second form of identity (e.g., birth date, identification number) before proceeding.

Additional strategies to prevent “wrong patient” medication errors can be found in Table 1.

Table

Strategies to Prevent “Wrong Patient” Medication Errors

Patient Registration
  • Ask for a full legal name (including junior/senior designations), birthdate, address, and telephone number.
  • Verify registration entries by asking the patient to repeat his/her name and at least one other identifier, or by cross-checking a photo identification for comparison.
  • Ask the patient/caregiver to verify the information on his/her armband (or registration card) before applying it.
Prescribing Medications
  • Require prescribers to verify the patient’s identity using two identifiers when prescribing drug therapy.
  • Employ CPOE systems that provide safeguards to assure correct patient identification before accepting orders.
  • Enhance the font size of patient names on order entry screens (and eMAR and ADC cabinet screens).
  • Limit the selection of patients from electronic records to only patients being treated by the prescriber.
Transcribing Medication Orders (Pharmacy and Nursing)
  • Eliminate transcription of orders by employing CPOE.
  • For paper orders, replace addressograph imprints with laser-printed identification labels to improve clarity.
  • When printing or imprinting orders, labels, or requisition slips, verify that the correct patient information appears on the items by comparing two unique patient identifiers in the medical record with the printed or imprinted items.
  • Keep patient identification labels in separate files or in each patient’s medical record.
  • Transcribe one patient’s orders at a time; fill out, print, or imprint request forms for one patient at a time.
  • Fax or scan orders to the pharmacy for one patient at a time and one page at a time. After verifying two unique identifiers, replace the orders in the medical record before faxing or scanning the next patient’s orders.
  • Verify patient identity by comparing two unique identifiers on the order and pharmacy profile when entering orders into the computer. Initially select the patient by entering the medical record number or scanning a barcode on the patient’s order set, and then verify the patient information on the screen using two unique identifiers.
  • Document oral orders directly onto the patient’s medical record or use a preprinted pad of paper with a template that prompts for all necessary information (e.g., patient’s full name, medical record number, date of birth). Confirm the patient’s identity by reading back to the prescriber the patient’s name and a second unique identifier.
  • Verify patient identity by comparing two unique identifiers on the order form and MAR when transcribing orders.
Dispensing Medications
  • Label patient-specific medications dispensed by pharmacy with at least two unique patient identifiers.
  • Dispense only one patient’s medications in each ziplock bag (or envelope, etc.).
  • Ensure the medication prescribed for the patient makes sense for the patient given his or her clinical condition.
  • Require an independent double-check that includes patient verification before dispensing selected high-alert drugs.
Administering Medications
  • Explain to patients why an identification process must be carried out by staff with each drug administration.
  • Tell patients the names of the drugs being administered and their purpose, and show them the packaging, so they can question any unexpected medications.
  • When possible, ask the patient/caregiver to state his or her name and at least one additional identifier for comparison with the MAR. Avoid verifying patient identity by passive agreement (e.g., “Your birthdate is October 28, 1981, right?”).
  • Ensure the MAR is available at the point of medication preparation (including at ADCs) and administration (in separate work areas for patients in ward-type settings [e.g., neonatal units, PACU] to prevent mix-ups with MARs).
  • Consistently employ barcode verification of patients at the point of care prior to drug administration.
  • Require an independent double-check that includes patient verification before administering selected high-alert drugs.
  • Ensure the medication being administered makes sense for the patient given his or her clinical condition.
Monitoring the Effects of Medications
  • Label all monitors that display diagnostic information using a standard patient verification process.
  • Verify at least two unique identifiers before posting/entering monitoring and test results on the patient’s record.
Strategies for Patients With Known Look-alike/Same Names
  • Verify patients using a medical record number rather than a birth date or address, since patients with the same last name may live at the same address, and multiple birth neonates have the same last name and birth date.
  • Employ computer system/screen alerts and/or addressograph plate/patient labels with a prominent notation to warn staff about possible name confusion and remind them to identify the patient by medical record number and name.
Reference
  • Schulmeister L. Patient misidentification in oncology care. Clin J Oncol Nurs 2008;12;(3):495–498.