Medication Error Sparks Transformation of Clinic’s Patient Safety Culture

“My heart just sank. I couldn’t believe it.”

These were the first thoughts of a physician upon realizing that a patient had received a medication he was allergic to, requiring emergency treatment and hospital admission.

After this error, the practice implemented several process changes to prevent similar events. Most importantly, though, the event spawned a true culture shift, and staff have become empowered to speak up about mistakes and concerns.

One of the nurses remarked about how this error gave staff an opportunity to renew their focus on safety. I hope sharing these stories and having a Just Culture enable all staff to talk openly and learn from each other to ensure the safest possible care. It’s why Safety Matters exists.

Thank you for reading,



Medical registerWhat Happened

Prior to a procedure, a nurse reviewed her patient’s allergies in the new electronic health record system recently implemented at BWH, and transcribed them onto a paper procedure form and the patient’s wristband, per the clinic’s protocol.

The nurse gave a brief handoff to a second nurse who would assist during the procedure, but did not discuss the complete list of allergies, as the first nurse was pulled away to care for another patient during the handoff.

The physician asked the procedure nurse to give the patient an antibiotic, but did not immediately enter the order in the computer. The nurse checked the paper form and wristband, which did not have this medication listed as an allergy. Because the patient had numerous allergies, the nurse asked the patient if he had taken the medication before or was allergic to it. The patient said he didn’t think he had ever taken it, and the nurse administered the medication.

Shortly after, the patient started coughing and speaking in a hoarse voice. The team called a code blue (the hospital medical emergency response team), and the patient was immediately taken to the ED for an allergic reaction and admitted to the hospital overnight for observation.

“We didn’t realize there was a mistake until after the patient was in the ED, and we had reviewed everything again in the electronic heath record,” said the nurse. “I felt absolutely horrible.”

The physician disclosed the mistake and apologized to the patient. The patient made a full recovery from the incident.

What Went Wrong:

Several factors contributed to this error:

  • The allergy screen in our electronic heath record was difficult to read, with more severe allergies highlighted in different colors.
  • The first nurse missed one of the patient’s allergies in the manual transcription to the paper procedure form.
  • The provider did not order for the antibiotic in computer (although did sign a paper order prior to administration)
  • Because the order was not in the computer, the computerized double check comparing the medications to the patient’s known allergies did not occur, and as a result the physician was not alerted to the contraindication.


 What We Did:

  • The practice changed its process to require all medication orders be entered into the electronic health record before administration, as an alert will warn staff about allergies.
  • All procedural documentation is now entered in electronic health record rather than on a paper form, and staff no longer write allergies on the patient’s wristband, due to the potential for transcription errors or omission.
  • The clinic practice also changed the workflow to include electronic health record based medication reconciliation and review of allergies with the nurse after the front desk staff print the list of allergies and current medications from the electronic health record, prior to the procedure.

Equally importantly, the error changed the culture of safety in this clinic. Staff began holding regular safety huddles as part of staff meetings to encourage open discussions about safety concerns and near misses.

One of the nurses noted that the focus of staff has shifted from task-based practice to being more mindful of nursing practice and the patient’s physical and emotional needs. There is also support from the multidisciplinary clinic leadership for better communication among all staff to improve the safety and quality of care. For instance, nurses are empowered to speak up if they need more time or resources to complete a thorough medication reconciliation or other tasks before proceeding with the procedure.

Just Culture Corner: Re-Engineering Systems to Reduce Human Error
BWH is committed to adopting the principles of a Just Culture and creating an environment where we feel safe and supported when speaking up about risks we see. Safety Matters highlights concepts and learning around this important culture change.

This story highlights an important Just Culture concept: the relationship between system design and human error.  Our system designs in health care often rely heavily on people “being careful.”  But because we are fallible, this over-reliance on our ability to “pay attention to detail” introduces risk into our processes.  Even when we are as careful as possible, there is an inherent rate of error in manual tasks such as transcription.  And under time pressure or in the face of distraction, as we often are in health care, this rate of error increases.

At the time of the above story, this clinic was using a manual transcription workflow. It was time-consuming, and staff were often under pressure to complete the transcription quickly.  The design of the allergy screen in the electronic health record was also problematic, and made it easier to inadvertently miss allergies during the transcription.  This time-compressed, manual process increased the likelihood of an omission during the transcription process (inadvertent human error).

The Just Culture response in this case was to work with front line staff to change the system design to reduce the likelihood of human error. Staff helped re-engineer the workflows of nurses and physicians. Nurses no longer transcribe allergies onto a wristband or paper form, eliminating this potential for human error. Physicians now enter orders into the electronic health record to allow the built in decision support to compare the order to the patient’s allergies. In addition, the eCare team updated the allergy screen, removing the highlight feature that contributed to this error.

It is difficult to fully eliminate the risks associated with human fallibility, and we all need to do our utmost to be safe.  But saying “try harder” or “be more careful” cannot be our sole safety strategy. In a Just Culture, we recognize that human beings are prone to error, and we do not punish for the inadvertent errors that any of us might make; instead, we design systems that are resilient to human fallibility.  This is how we can make care safer.


To protect patient identities, we have sometimes changed the patient or clinical team member details.  Unless otherwise stated, all the other details of the events are presented as they occurred.