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Unverified Patient-Reported Errors
When faced with a possible medication error, obviously one should never assume that it is just a false alarm. Timely investigation is required, and a high index of suspicion is paramount. On the other hand, assuming that patient-reported events are always accurate can also be dangerous and costly if they are not verified via a timely investigation. In an unusual turn of events, we recently learned about a false alarm that set into motion unnecessary anxiety and wasted resources when a potentially fatal error was suspected, but not confirmed. The false alarm involved a patient who reported too-rapid home infusion of chemotherapy, but later analysis revealed that no error had actually occurred.
The Patient-Reported Error
A patient with cancer was receiving her second cycle of intravenous fluorouracil as a continuous infusion over four days via a Leventon Dosi-Fuser, a portable elastomeric delivery system. A hospital pharmacy had prepared the chemotherapy, but the patient was receiving the infusion at home, with delivery and follow-up by a home-infusion service. After one day, the patient called the home-infusion triage nurse to report that the entire contents of the infusion had been delivered over 30 hours instead of the planned 96 hours (four days). The nurse called the covering oncology fellow, who recommended sending the patient to the emergency department (ED) for evaluation.
After advising the patient to go to the ED, the triage nurse called the ED charge nurse and physician to alert them to the impending visit for what appeared to be a fluorouracil overdose due to a delivery device failure. The home-infusion triage nurse also contacted the on-call home-infusion pharmacist, who then called her supervisor. The home-infusion service asked the nurse to save the device so it could be inspected the following day.
The patient presented to the ED and was evaluated by a nurse and physician (different than the nurse and physician initially contacted by the triage nurse). The nurse had received a report from the charge nurse and believed the too-rapid infusion had been confirmed. She had never seen a Leventon Dosi-Fuser before and, although she looked at it, she failed to notice that the solution had not entirely infused. Using personal protective equipment, she disconnected the Dosi-Fuser from the patient and placed it into a hazardous waste bag. The oncologist came to the ED and looked at the device through the bag. He also was not familiar with the device and assumed it was empty. He did not remove it from the bag for closer inspection because it contained chemotherapy and was labeled as hazardous waste.
Both the oncologist and the ED physician had called poison control and were told that the rapid infusion of fluorouracil could cause a potentially fatal overdose that should be treated accordingly. The oncologist made arrangements for the patient to receive a then-investigational antidote, uridine triacetate (now approved as Vistogard, Wellstat Therapeutics), which would require airfreight delivery from a distant state. This was ordered with the assistance of the inpatient pharmacist, who also took possession of the Dosi-Fuser device. The inpatient pharmacist called his assistant director, who alerted their director, but no one from the inpatient pharmacy actually looked at the Dosi-Fuser device.
The next morning, word of the error reached the ambulatory oncology center pharmacist. He retrieved the device that was removed from the patient and immediately noticed that it did not “feel” empty—this was obvious to him and his staff because they handled the devices often. After closer inspection and weighing the device, they learned it was not empty, and no overdose had occurred. Fortunately, because the uridine triacetate had not yet arrived, the patient did not receive the antidote. The patient was reassured that she did not receive an overdose and was discharged home.
There are a number of lessons to be learned from this event, many of which can help avoid a false alarm or a failure to see and appreciate important risks.
Confirm Patient-Reported Errors
Keep a High Index of Suspicion
Examine Evidence During Handoffs
Promote Inspection and Monitoring
Consult Staff With Required Skills and Knowledge
Because the error reported by the patient in this case turned out to be a false alarm, actions taken by the health care practitioners in response to the reported error resulted in an adverse outcome for the patient—the premature disconnection of the Dosi-Fuser and interruption of the full course of therapy. The patient never received the full dose of fluorouracil for that cycle, and the impact this may have on the overall treatment outcome remains unknown. Had a more thorough investigation been conducted when the patient first presented to the ED, a lot of anxiety, medical care, and resources could have been spared, and the adverse outcome could have been avoided.