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Many organizations are also promoting just culture, which encourages reporting, near-misses and patient safety events and focuses on psychological safety and promoting a non-punitive reporting culture.

Jennifer Sanchez

Jennifer Vuu Sanchez, RN

Patient Safety Program Director, CRICO

A 30-year-old woman experiencing her first pregnancy, presented to the Labor and Delivery (L&D) unit. It happened to be near the time of a shift change. 

Before finishing her shift, the RN was preparing the delivery room for the oncoming staff while also getting medication to treat the patient for her complaint of nausea. The nurse obtained three vials of medication: Zofran for nausea, and lidocaine and Pitocin for use after the delivery. She planned to start a peripheral intravenous catheter and administer the Zofran.

While preparing to administer the Zofran, the RN was distracted by a call about another patient who had just arrived on L&D in active labor. After starting the IV on the first patient, the RN intended to administer the Zofran, but she mistakenly administered 10mg of Pitocin as an IV push (Pitocin is typically titrated). The Pitocin and Zofran vials both had green caps, and the RN immediately recognized the error.

The patient reported pain, and her abdomen became firm. The nurse was not able to find fetal heart tones. The team quickly administered terbutaline to counteract the effects of the Pitocin and the patient required an emergent cesarean delivery. A healthy infant was delivered within 18 minutes of the administration of the Pitocin. The obstetrician disclosed the error to the patient who has an incision scar. For any future births, she faces risks associated with a prior cesarean delivery.

The patient brought a medical malpractice claim, alleging the nurse caused pain and suffering from an unnecessary procedure related to wrong medication administration. The case was settled in the low range.

To discuss the patient safety and risk management aspects of this case, we are joined now by Jennifer Vuu Sanchez, an RN who worked as Gyn/Oncology nurse at Massachusetts General Hospital, and is now a program director at CRICO, the patient safety and medical malpractice program for the Harvard-affiliated Medical Institutions.

Q.) Jen, thank you for joining us.
A.) Thanks, Tom. Thanks for having me.

Q.) So. This was a pretty bad outcome for the patient and we know that there are ways that we try to remember to do everything right. And we dont always do everything right, but one of the things we talk about are the “five rights” for medication administration and how do these five rights sort of help us prevent a wrong?
A.) Thats a great question, Tom. The five rights of medication administration are generally regarded as a standard for safe medication administration practices, and it can help to reduce medication errors and patient harm. So ensuring that you have the right patient, right drug, right dose, right route and right time is an essential part of the process. And these are really the basic principles and often the go-to in busy and stressful environments in a simple way to protect yourselves as clinicians. In addition, nurses are frequently the last check prior to medication administration in applying the five rights framework. In practice, it can help to reduce errors and harm.

Q.) Right. And its not failsafe, is it? What are the flaws in the system at this facility that we could identify? Can you describe some of them?
A.) Yeah. Yeah. Youre right. The five rights of medication administration focuses on individual factors and not necessarily on system flaws. So it is possible that even if a nurse completes the five rights of medication administration, there could be systems issues in place that may interfere with safe medication practices. So in this case study, the systems issues that stand out include, medication lookalikes, which, for this is the packaging for the Zofran and the pitocin were similar where they both had green caps. This created confusion in a stressful and busy environment and contributed to the medication error.

Another systems issue is related to the barcode scanning. There was not use of the barcode scanning technology in this case. There was a study by Poon and colleagues which found that 41% reduction of timing administration errors and a 51% reduction in potential adverse drug events from these errors. So the barcode scanning can greatly help in reducing medication errors. And then lastly, the medication process, a procedure utilized on this unit opened the nurse up for potential errors. And as a result, in this case the medication process was reviewed, and changes were made.

Q.) Yeah, now what are some of the ways we’ve seen that are effective, that institutions and even individual clinicians work on to plug the holes in our systems?
A.) Effective ways that we have seen institutions and individual clinicians work to plug the holes in our systems include safety reporting, conducting root cause analyses and analyzing data and outcomes, and sharing the learnings. So safety reporting or incident reporting is crucial to a learning organization. It is a foundational piece of protection for yourself as a clinician. It can provide insights to how, why, and where an event is occurring. Incident reporting also allows an organization to learn where improvements and resources should be focused. Many organizations are also promoting just culture, which encourages reporting near-misses and patient safety events, which can also be beneficial for everyone, and focusing on psychological safety and promoting a non-punitive reporting culture.

Q.) Well, thank you. Jennifer Sanchez is a patient safety program director at CRICO. Im Tom Augello for Medmal Insider.


  • Jennefer Vuu Sanchez, RN

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MedMal Insider

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About the series

Even in the safest healthcare setting, things can go wrong. For more than 40 years, CRICO has analyzed MPL cases from the Harvard medical community. Join our experts as they unpack what occurred and the lessons learned for safer patient care from the causes of these errors.


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