Friday, November 10, 2006

A safety save results in systems change

Despite rapidly expanding technology, stringent protocols and improved processes, medication errors are always possible in patient care settings.

Peggy Rankowitz, RN, BSN, OCN, found that out firsthand Wednesday on A-2. Fortunately, she exhibited the type of behavior needed to ensure patient safety at Backus Hospital.

It all began when Ms. Rankowitz went to the Pyxis machine on the oncology floor to retrieve a Heparin drip for one of her patients. She pushed the button labeled “Heparin drip” and pulled out the bag. As she removed the outer wrap, she began the process of ensuring the “five rights” – the right medication, right dose, right patient, right route of delivery and right time.

Although she has done this countless times over the course of her 16-year nursing career at Backus, this time it paid off. Something was very wrong; she was actually holding a bag of premixed Theophylline.

The Heparin and Theophylline are made by the same manufacturer and are very similar looking, so Ms. Rankowitz’s steadfast attention to medication safety protocol avoided a significant medication error, and prompted an immediate Hospital-wide systems change.

“My heart rate went up,” Ms. Rankowitz said. “It was quite alarming. This is why they teach us to do our five checks – it’s part of the job. You always have to check, because we deal with so many medications, so many patients, and they are always coming and going. We have to keep in mind that it is always a possibility.”

The U.S. Food and Drug Administration certainly agrees. The USDA reports that medication errors injure 1.5 million people annually, and the extra costs of treatment related to these injuries in hospitals nationwide each year is $3.5 billion. Approximately 41 percent of all fatal medication errors involve giving an improper dose, 16 percent giving the wrong drug and 16 percent using the wrong route of delivery.

The results of what can happen when medication checks are not properly done were magnified at an Indianapolis hospital recently, where nurses inadvertently gave two newborns adult doses of Heparin. The vials of adult and baby doses were of similar size and color, which allegedly prompted the mistakes.

In the case at Backus Hospital, Ms. Rankowitz not only noticed the problem but took steps to eliminate the chance of the same error occurring again. She re-accessed Pyxis to ensure there were no other Theophylline bags in the wrong places, and alerted her supervisor to what had happened. Her supervisor then notified the Pharmacy, which immediately evaluated the situation and decided to stop stocking Theophylline bags, which are not used very often and look too much like the more commonly used Heparin. This means that this particular medication mix-up could not possibly happen again.

“This is exactly the type of behavior we expect from our staff,” said Karen Long, RN, Vice President and Chief Nursing Officer. “This is a real-life scenario that underscores the importance of reading the label on all drugs, double-checking them before they are administered and alerting the proper people to ensure that a medication error doesn’t happen again. I commend Peggy for her efforts, and encourage all of our staff to follow her example.”

Glennie Poletti, RN, A-2, said Ms. Rankowitz’s actions are symbolic of what nurses should continuously strive for – routinely keeping patient safety at forefront of everything that they do.

“This is what we do all the time,” Ms. Poletti said. “It’s a routine that we follow, it’s how we practice, and this just goes to show that what we are doing really works.”

Mary Bylone, RN, Assistant Vice President of Patient Care Service and Patient Safety Officer, said caregivers must remain vigilant to prevent human error, even though when you do things over and over it might seem like a waste of time.

“This is a great example of how following established, routine protocols can improve patient safety,” Ms. Bylone said. “Peggy’s attention to detail, and her taking the initiative to notify the appropriate parties, is the type of behavior we want to see in our caregivers. I can’t emphasize enough how important this is to our patients. ”

Peter Shea, MD, Medical Director, said following established processes, and putting the patient first, is the basis for error prevention. He said Ms. Rankowitz’s follow-up was extremely important.

“Peggy’s actions directly resulted in an immediate hospital-wide systems change,” said Dr. Shea. “She did a tremendous job, and our patients are safer because of her.”

Ginny Mabesoone, RN, Clinical Director of A-2, said Ms. Rankowitz has always exhibited the traits of a remarkable caregiver, and her recent efforts only add to her reputation.

“Nurses like Peggy are tremendous role models,” Ms. Mabesoone said. “She deserves an enormous amount of credit for what she did this week, and for her consistent efforts to provide the best care possible to our patients.”

Medication safety is a focus of the Joint Commission on Accreditation of Healthcare Organization’s National Patient Safety Goals. Anyone with any questions about the JCAHO goals, or suggestions to help Backus improve patient safety, can call Ms. Bylone at ext. 2771, or Joe Hughes, Director of Quality Improvement, at ext. 2345.


  • My advice to every patient is ASK, ASK, ASK what you are being given. Do not assume that it is correct!

    By Anonymous Anonymous, at November 10, 2006 4:45 PM  

  • That's a good point. Patients and hospitals need to be partners in care. Ask questions, and speak up. Hospitals that value your safety will be happy you did.

    By Anonymous Anonymous, at December 01, 2006 2:54 PM  

  • I work at a facility in which CEFOXITIN was ordered, Pyxis dispensed (and the patient was given) CEFOTAXIME.

    When I reported this error it was squashed. As far as my institution is concerned, this didn't happen. We're happy to report a 100% safety record.

    By Anonymous Anonymous, at January 30, 2007 7:23 PM  

  • Kudos to Ms. Rankowitz and the pharmacist for catching this near-miss and especially for acting systematically to prevent it from happening again!

    For a story on another kind of look-alike dispensing error, see

    By Blogger Ken Farbstein, at March 15, 2007 3:33 PM  

Post a Comment

<< Home