Case Study: Medication Administration Error Leads to Cardiac Arrest and Patient Death

Laura M. Cascella, MA, CPHRM

Case Details

The patient was a 72-year-old male who had a past medical history of hypertension, anemia, and cirrhosis. Prior to hospital admission, he had an outpatient gastrointestinal (GI) screening and was found to have ectasia, cholangiectasis, diverticulosis, and hemorrhoids.

In September, the patient presented to an emergency department with weakness, dark stools for several weeks, and esophageal varices. His hemoglobin was very low at 5.0 gm/dL, and he had elevated troponin levels. He was admitted to the hospital and received cardiology and gastroenterology consults. Further testing revealed that his elevated troponin levels were not of cardiac origin.

The patient was transferred to the intensive care unit (ICU) to stabilize his hemodynamic status prior to having an upper endoscopy. As staff were getting ready to take him for the procedure, he suffered a cardiac arrest. He was resuscitated and intubated, but later coded again and died after several days. An investigation determined that the cause of the cardiac arrest was a medication administration error. While the patient was in the ICU, a nurse had mistakenly given him rocuronium, a powerful paralytic agent, instead of vancomycin.

Discussion

Medication errors and adverse events are a serious and persistent patient safety and liability issue across healthcare settings. An analysis of more than 3,000 malpractice cases found that medication-related cases — in comparison with other malpractice cases — involve a larger percentage of deaths, more frequently close with an indemnity payment, and close with a considerably higher average payment.[1]

The medication process is complex, particularly because of the number of steps and individuals involved, the volume of medication orders in hospitals, and the increasing number of prescription medications on the market. The medication administration phase is particularly risky in hospitals, which is the point at which the medication error occurred in this case.

A root cause analysis found that both human and system factors contributed to the administration of the wrong medication and the patient’s subsequent cardiac arrest and death. The nurse mistakenly selected rocuronium rather than vancomycin from the automated dispensing cabinet (ADC). When she scanned the medication, an error occurred with the code, which led her to perform an override of the system. Further, it was revealed that the pharmacy had stocked rocuronium in the ADC, even though organizational policy stipulated that it should not be available on the floor.

Although many hospitals have implemented safety technologies to help detect and prevent medication errors, these systems are not without risks. For example, ADCs can increase risks and create safety hazards if they are not used appropriately and as part of a well-designed system. In this case, the pharmacy stocked a high-alert medication in the ADC against organizational protocol. Then, the system did not work as intended and produced an error code when the nurse scanned it. Finally, despite the safety concerns related to rocuronium, the nurse was able to override the system and administer the medication anyway.

A system of consistent checks and balances and safety protocols could have helped avoid this error and its unfortunate outcome. For example, the following strategies may help create an additional layer of safety in the medication process:

• Use simulation testing with new technologies to identify potential problems, unintended consequences, and workarounds that might lead to medication errors.
• Provide comprehensive training and education on medication processes and technologies to help ensure providers have competency.
• Develop adequate policies and procedures for managing high-alert medications, and provide thorough education on procedures for prescribing and administering these drugs as well as for monitoring patients who receive them.
• Assess provider workflows and identify strategies to improve administration safety, such as limiting interruptions, standardizing processes, using independent double-checks for high-alert medications, and implementing medication safety rounds.
• Implement medication administration policies that require providers to verify the patient’s identity; verify the correct medication, dose, route, and time of administration; check the medication label against the medication order; visually inspect the medication and verify its expiration date; and check for contraindications or potential drug interactions.
• Develop a plan to (a) ensure ongoing assessment of medication technologies, (b) review user competency with various systems, and (c) identify errors and near-misses associated with medication technologies and determine reasonable mitigation strategies.
• Use pharmacy-profiled ADCs to direct providers to patient-specific medication profiles, and limit medications to those reviewed and approved by pharmacists.
• Have an interdisciplinary group determine what medications will be available on override for ADCs, who can remove medications on override, and what types of medications will be available on override based on clinical location.
• Monitor adherence to pharmacy policies and procedures for safe stocking of ADCs (e.g., standardized medication names, barcode scanning, and independent double-checks).
• Require a witness (a licensed practitioner) to provide verification when high-alert medications are retrieved on override.

In Summary

Medication errors are a long-standing and persistent threat to patient safety in various healthcare settings, but particularly in hospitals and large health systems where the medication process often involves multiple steps, many people, and complex processes. Technologies can help alleviate some of the risks associated with medication errors, but they also can create new perils when they are not properly implemented and used.

Healthcare organizations should review their medication safety processes, identify potential human factors and system factors that might be vulnerable to errors, and devise strategies to address these areas of risk.

Learn More

For more information about medication safety in the hospital setting, see the following MedPro resources:

• Checklist: Antibiotic Stewardship in Hospitals
• Checklist: Medication Inventory Management for Hospitals and Healthcare Facilities
• Checklist: Reducing Medication Selection and Administration Risks Associated With Automated Dispensing Cabinets
• Risk Tips: Planning for and Optimizing the Use of Computerized Provider Order Entry
• Tackling Medication Prescribing, Administration, and Management/Monitoring Errors in Hospitals

Endnote

[1] CRICO Strategies. (2016). Medication-related malpractice risks: CRICO 2016 CBS Benchmarking Report. Retrieved from www.candello.com/Insights/Candello-Reports/Medication-Related-Report

Disclaimer

This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.

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