A 65-year-old woman with rheumatoid arthritis and
chronic obstructive pulmonary disease (COPD) was admitted to a
medical unit during the night with worsening shortness of breath.
Orders were written at 2:00 AM for prednisone 60 mg daily and for
continued administration of her daily methadone dose of 80 mg. The
medications were administered by the night-shift nurse when they
arrived on the unit at 6:00 AM, in accordance with a new policy
that specified that all newly ordered medications be administered
to patients within 4 hours.
The nurse assigned to this patient for the day
shift also administered the two medications at 9:00 AM to comply
with another policy regulating daily medication administration.
When the day-shift nurse documented his administration of the two
medications, he realized that the same medications had been
administered 3 hours earlier. He immediately notified the
physician, and continuous pulse oximetry and hourly vital sign
checks were conducted to watch for oversedation from the methadone
overdose. Fortunately, the patient was able to tolerate the extra
doses of prednisone and methadone with no lasting effects.
This incident illustrates how
multiple reasonable system policies can produce an unreasonable
result. The policy mandating that all new medications be given
within 4 hours of being ordered had just been implemented a few
days before the incident, while the policy of administering all
daily medications between 8:00 and 10:00 AM had been rigorously
enforced for many years. Both were policies designed to enhance
effectiveness and safety but, applied together, introduced a threat
to patient safety.
1. Senge P. The Fifth Discipline: The Art and
Practice of the Learning Organization. New York, NY: Doubleday
Business; 1994. ISBN: 978-0385260954.
2. Cohen MR, ed. Medication Errors, 2nd ed.
Washington, DC: APhA Publications; 2007. ISBN: 978-1582120928.
3. ASSESS - ERR™ Medication System
Worksheet. Horsham, PA: Institute for Safe Medication Practices;
2006. [Available at]
Table. Key Elements That Organizations Should
Consider When Developing System Strategies to Reduce or Eliminate
Drug labeling, packaging, and nomenclature
Drug storage, stock, and standardization
Drug device acquisition, use, and
Competence and staff education
|Quality processes and risk management
ASSESS - ERR™ Medication System Worksheet © 2006 ISMP.
Reprinted with permission from the Institute for Safe Medication
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