Safety Reporting Leads to Safer Systems

February/March 2016

Dear Readers,

If an error occurs once, it could easily happen again – unless it is reported. This is why we believe it is critical that staff speak up about all errors, even those that are caught before they reach a patient. When we are made aware of an error, we have the opportunity to examine what went wrong and change our systems to prevent future errors.

One of the ways we ask staff to report errors is via an electronic safety reporting system. Reporting a safety event puts into action a non-punitive review of what happened and can lead to system improvements and safer patient care. Staff should file a safety report when they are involved in an adverse event; find a patient care error even if they were not involved; nearly make a mistake but catch it; or see a potentially hazardous condition.

In this issue of Safety Matters, we bring you two examples of safety reports that led to system improvements, making care safer for all of our patients.

Thank you for reading,


Karen Fiumara, PharmD, BCPS
Director, Patient Safety
Brigham and Women’s Hospital

Safety Report 1: Duplicate Dose
Please note that the case details have been slightly modified to ensure patient privacy.

What Happened
Nurse A was caring for a patient, Susan, and administered a dose of cough suppressant, which could be taken on an as needed basis every 8 hours, at 7:00 AM. Susan’s next dose, if needed, could therefore be given at 3:00 PM. That afternoon, a second nurse (Nurse B) was assigned to care for the patient while Nurse A was off the unit. Nurse B administered the next dose of medication because Susan was coughing. When Nurse A, resumed care of Susan, she gave her what she believed was Susan’s second dose of cough suppressant at 2:30 PM. Nurse A administered the medication at 2:30 p.m. because Susan was scheduled to leave the unit for testing and would not be back by 3:00 PM when the dose was originally scheduled. The nurse received a message in the electronic health record that the dose was being given early, “Based on the ordered frequency, this medication is possibly being administered too close to another administration.  Please review previous administrations to verify appropriateness.”  The message wasn’t surprising since she was purposefully giving her the second dose 30 minutes early. What she didn’t know is that Susan had already received the second dose from Nurse B. Fortunately, Susan was not harmed by this additional dose. 

What We Are Doing
When Nurse A filed the safety report about this event, she included an idea for avoiding similar events in the future. She suggested that the warning box in the electronic health record that highlights the early medication time, also include the time the last dose was given.  In this case, the warning would have alerted her to the time Nurse B administered the medication and prevented the duplicate dose.

Based on this error, safety report and improvement suggestion, IS (Information Services) is adding a best practice alert (BPA) displaying the last administration time for all PRN (as needed) medications.

Safety Report 2: Delayed Medications

What Happened
A baby in the NICU who was exposed to addictive opiate drugs while in the mother’s womb was prescribed clonidine, a medication given to reduce the baby’s symptoms of opiate withdrawl.

The medication order prompted the Pharmacy to prepare two doses to be delivered to the NICU – one to be given to the baby immediately and one to be administered later that night. The medication dispensing system correctly printed two preparation labels, but in error printed only one patient label for the medication, so only one dose was actually delivered to the floor. Although only one dose was delivered to the floor, both doses were recorded in the electronic health record as being prepped, checked and delivered to the NICU.

When the nurse went to give the baby the second, night-time dose, it was not available, leading to a delay in medication administration while she called the Pharmacy to request the dose.

What We Are Doing
Nurses and pharmacists noticed this same delay in medication delivery for this and other NICU oral syringe medications over a few evenings for other patients, and several safety reports were filed. Because of this, the medication dispensing system has been fixed so that the correct number of labels are printed as the medications are being prepared.

The system now accurately captures the number of doses prepared and delivered to the unit. These system improvements will help to ensure that needed medications are available for our patients at the right time.

Just Culture Corner

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 will highlight a new concept or learning around this important culture change in each issue.

Safety Report 1: Duplicate Dose

Staff at the front line are in the best position to identify and help fix problems.  We all have a role in reporting concerns and finding solutions. 

This story is an important example of how a culture of safety makes care safer.  Our staff at the front line have the most insight into where our processes could break down and how they can be improved.  But, if staff fear speaking up about the problems they see (and mistakes or at-risk choices that any of us might make), many of these risks may remain “under the radar” until there is a major patient harm event.  In contrast, in a culture of safety, staff not only feel safe speaking up about the risks they see, but they are encouraged to do so.  And, staff are encouraged to think through potential solutions to reduce risk.  In the duplicate dose case, Nurse A not only highlighted the safety risk but helped develop a solution (BPA displaying last administration time for PRN medications), reducing the risk of duplicate PRN doses in the future.   Our ultimate goal is to work with front line staff and use these Just Culture concepts proactively to recognize and reduce risks before the near miss or adverse outcome.  This is how we can become truly safe.

Safety Report 2: Delayed Medication

Sometimes our systems can directly contribute to error, and safety reporting from the front line helps us quickly identify system problems that we need to fix.

The Just Culture approach is not about finding fault, it is about managing risk.  Sometimes the risk is in our systems, sometimes it is in our behaviors, and very often it is both.  This case is an example of how the risk was in the medication dispensing system, which failed to print both medication labels.  Quickly identifying this system issue through safety reports allowed for changes to the dispensing system.    And, fixing this system issue led to a label printing solution not only for clonidine, but for other NICU oral syringe medications as well.