- Describe the just culture approach to
investigating errors in health care.
- Analyze system contributions to errors
- Identify best sources of information for
designing a response to an error.
- Distinguish accountability for failure
and learning from failure.
An infant was born prematurely at 30 weeks
weighing only 1.8 kg. In the neonatal intensive care unit, he was
started on total parenteral nutrition (TPN) with Premasol amino
acid solution at 3 g/kg/d and dextrose 12.5%, 5 mg/kg/min. After
being maintained using those solutions for the first 2 days after
delivery, the care team added lipids on day 3. This was ordered as
lipid emulsion 20% at a rate of 0.19 mL/hr.
The neonatal intensive care unit had frequent
orders for this treatment and kept a stock of lipid emulsion on
site. This practice avoided the delay between ordering, sending the
order to the pharmacy, and waiting for the pharmacy to dispense the
new TPN solution.
Within 4 hours of beginning the lipid emulsion
administration through the TPN line using a smart pump, the
infant's condition worsened. He showed signs of respiratory
distress, pulmonary hypertension, coagulopathy, and liver failure.
Soon after, the infant suffered a cardiac arrest and died.
As the symptoms displayed by
this premature infant suggested lipid overload, the dose and rate
of administration of the lipid formulation were assessed.
Assessment revealed that the pump was set to deliver 19.0 mL/hr. In
the process of calculating the dose with the concentration of lipid
emulsion available on the unit, the RN had erroneously set the pump
to deliver 100 times the ordered dose of 0.19 mL/hr. Upon discovery
of the error, the nurse involved was fired by the hospital and her
license was revoked. The sequence of events and underlying reasons
for the error were not investigated further.
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2. Gawande A. Complications: A Surgeon's Notes on
an Imperfect Science. New York: Picador; 2003. ISBN:
3. Pellegrino ED. Prevention of medical error:
Where professional and organizational ethics meet. In: Sharpe VA.
Accountability: Patient Safety and Policy Reform. Washington, DC:
Georgetown University Press; 2004:83-98. ISBN: 158901023X.