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WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by patient safety experts and published monthly.

Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

This Month's WebM&Ms

A 38-year-old man sustained multiple injuries in a motorcycle crash, including head trauma, chest injuries, and spinal... Read More

A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury. A head CT scan was read as... Read More

These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous... Read More

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A 38-year-old man sustained multiple injuries in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. Attempts to intubate him to manage his respiratory distress were unsuccessful and he underwent emergency cricothyroidotomy. Despite initial neurological evaluations indicating normal extremity movements, he developed progressive paralysis of his lower extremities over the hospital course. A delayed MRI revealed a significant epidural hematoma compressing his spinal cord from C3 to C7, prompting emergency surgery. Despite decompression, he suffered permanent paralysis. The commentary highlights the cognitive pitfalls associated with managing and processing large volumes of clinical information and the importance of effective communication and active engagement among all clinical team members.

A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury. A head CT scan was read as normal and he was diagnosed with a minor head injury and discharged without any specific treatment. Three weeks later, he presented with ongoing symptoms including worsening cognition and increased headache and was diagnosed with post-concussive syndrome and discharged without specific treatment. He was later diagnosed with a large frontal subdural hematoma requiring urgent surgery. The commentary discusses risk factors for delayed acute subdural hematoma and the importance of repeat brain imaging in patients with risk factors and persistent symptoms.

These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous ground-level falls. The commentary summarizes risk factors for fall injuries among high-risk populations (such as older adults), appropriate use of fall assessment and prevention strategies, and strategies to improve communication between healthcare team members to reduce the risk of patient falls.

A man presented at the emergency department (ED) after a motorcycle crash. He had superficial lacerations on his left elbow, where wood chips were noted on exam and x-ray but were not fully removed before discharge. He was discharged with antibiotic prescriptions, but returned three days later with worsening symptoms, including pain, swelling, and pus, leading to additional foreign material being removed and further antibiotic treatment, but without repeat x-rays. Ultimately, he developed osteomyelitis, requiring multiple surgeries and a long hospital stay due to the retained foreign bodies. The commentary highlights the importance of evaluating patient risk of wound infection and poor wound healing, the role of imaging modalities to help identify foreign material in wounds, and diligent follow-up to prevent complications.

An 8-year-old boy undergoing a neck mass aspiration experienced a sudden drop in oxygen saturation and heart rate, requiring CPR and intubation, due to being administered nitrous oxide instead of oxygen following a maintenance error by an inadequately trained employee. The patient was transferred to the intensive care unit (ICU) on a ventilator but remained unresponsive and died. The commentary discusses several approaches to improving patient safety during anesthesia administration in the surgical suite, such as use of oxygen analyzers and considering hypoxic gas mixture as the cause for sudden deterioration.

A 54-year-old man with a history of tobacco use presented to the emergency department (ED) with acute chest pain. He was initially stable upon arrival, though with signs of fluid overload and electrolyte abnormalities including hyponatremia and hyperkalemia. Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions for hyperkalemia, the patient deteriorated rapidly into cardiac arrest characterized by Torsades de pointes, which was mistaken for ventricular fibrillation. Despite resuscitative efforts, he did not achieve return of spontaneous circulation and autopsy revealed sudden cardiac arrest without myocardial infarction as the cause of death. The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect treatment and patient harm.

A woman underwent surgery for carpal tunnel syndrome without complications and was discharged with instructions to avoid soaking her hand in water (to reduce infection risk) and return for suture removal in 10 days. Despite reporting symptoms such as warmth, redness, and pain in her wrist shortly after surgery, her concerns were not adequately addressed by the surgeon's office. The patient returned for suture removal and visit notes stated that the wound was not infected or swollen. However, the patient continued to report pain, swelling, redness and oozing at the incision site after suture removal. Two weeks later, she presented to the emergency department (ED) and diagnosed with a severe infection, leading to multiple hospitalizations and permanent impairment of her right hand. The commentary discusses the importance of preoperative discussions about post-operative care, including sterile practices, and the use of protocol-based management strategies for medical office personnel to ensure that patient interactions and communication are appropriately documented and acted upon

An adolescent with type 1 diabetes presented to the emergency department (ED) with dizziness, fatigue, and a “high” reading on her home blood glucose monitor. She was diagnosed with diabetic ketoacidosis (DKA) likely due to insulin pump malfunction. Despite initial treatment, her condition did not improve as expected. Later, it was discovered that an incorrect weight was used to calculate her insulin drip rate, based on a guessed weight provided by the patient upon admission. Once her actual weight was used to adjust treatment, her DKA resolved rapidly within 12 hours. The commentary discusses how human factors engineering and electronic health record (EHR) functionalities can optimize weight measurement during patient encounters and the role of clinical pharmacists in the ED to improve medication safety.

During elective rhinoplasty, a patient became aware that she was awake. She heard the conversation among the surgical team members and felt that the breathing tube was pushed up against the inside of her throat, impeding her ability to breathe. She was unable to move but recalls making a “monumental effort” to utter a small groaning noise, which alerted the surgeon to the fact that she was awake. She heard the surgeon verbally acknowledge her condition and offer reassurance that the operation was almost over. During the first follow-up visit, the surgeon did not address the situation, so the patient brought it up at the end of the visit. The surgeon seemed surprised and embarrassed that the patient remembered waking up during the operation but could not explain what happened. The commentary discusses the risk factors for intraoperative awareness, approaches to prevent awareness, and the importance of validating and addressing the patient’s experience, including addressing symptoms of post-traumatic stress syndrome. 

A 55-year-old woman with a history of panic attacks, obesity, and untreated hypertension, experienced syncope after feeling flushed and lightheaded. On arrival at the emergency department, she had severely elevated blood pressure and hypoxemia. Diagnostic tests revealed acute heart failure exacerbation with pulmonary edema, marked elevation of brain natriuretic peptide (BNP), and elevated troponin-I. Despite treatment with diuretics and antihypertensives, her condition deteriorated, leading to intubation due to respiratory failure and subsequent cardiac arrest; cardiopulmonary resuscitation resulted in with return of spontaneous circulation. However, she suffered from ischemic stroke and intracranial hemorrhages, ultimately leading to a transition to comfort care and subsequent death. The commentary discusses the contraindications for beta-blockers in the setting of acute decompensated heart failure and appropriate treatment for hypertensive emergencies in the emergency department and intensive care unit. 

A 19-month-old boy was being transferred to a tertiary medical center from another emergency department after undergoing comprehensive resuscitation efforts due to cardiopulmonary arrest. The transport clinician intended to administer rocuronium (a neuromuscular blocking agent) to treat ventilator desynchrony, but instead unintentionally administered flumazenil (a benzodiazepine antagonist). The clinician promptly corrected the error by administering the appropriate dose of rocuronium. The commentary highlights the importance of “double checks” during medication administration and how both technologic approaches and human factors engineering principles can support safe medication administration practices.

A 67-year-old man with severe low back pain was admitted to the hospital for anterior lumbar interbody fusion (ALIF) with bone autograft from the iliac crest. The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with the bone graft donor site open and oozing blood. In the postanesthesia care unit (PACU), the nurse called the attending physician three times to report hypotension and ongoing bleeding. Each time, the surgeon ordered hetastarch for volume expansion. Over the next 14 hours, the patient’s blood pressure remained at or below 90/60 with continued complaints of back and pelvic pain. The next morning, the patient was unresponsive and in severe hypovolemic shock. Electrocardiography confirmed a non-ST segment elevation myocardial infarction (NSTEMI). The patient was transferred to an intensive care unit and resuscitative efforts were initiated, but the patient expired from multiorgan failure resulting from hypovolemic shock. The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding and how a culture of safety can enable care team members to voice concerns about patient safety. 

A 36-year-old woman with class 2 obesity underwent a difficult laparoscopic hysterectomy, performed in the lithotomy position with a steep head down (Trendelenburg) position. Intermittent pneumatic compression devices were placed on both calves to prevent venous thrombosis (DVT), but on awakening from general anesthesia, the patient complained of severe pain in the right leg. The gynecologist made a presumptive diagnosis of DVT and put her on subcutaneous dalteparin at therapeutic dosing and acetaminophen and oral morphine for pain relief. The patient continued to complain of severe pain and paresthesias in her right calf and doppler ultrasound scan was negative for DVT. The next day the orthopedic on-call team was consulted and diagnosed compartment syndrome of the right leg. The patient required fasciectomy of the right leg and excision of necrotic muscle tissue, with a prolonged hospital stay. The commentary discusses how patient positioning during surgery can increase the risk for surgical complications, the role of interdisciplinary teamwork to achieve optimal positioning, and the importance of early identification of compartment syndrome to prevent permanent injury. 

Five weeks after gastric bypass surgery, a woman experienced persistent nausea and vomiting, leading to dehydration and multiple outpatient treatments. Despite visiting an outpatient clinic and emergency department (ED) for ongoing symptoms and significant weight loss, the nausea and vomiting persisted. Eventually, she was admitted to the ICU with pancreatitis and dehydration. Subsequently, she exhibited neurological symptoms including difficulty walking, tingling sensations, and cognitive impairment. She was discharged with orders for total parenteral nutrition (TPN). Three days after discharge, she was readmitted for worsening confusion and profound motor weakness, which progressed to respiratory failure requiring mechanical ventilation. Laboratory tests revealed an extremely low thiamine level, and the patient was diagnosed with advanced Wernicke-Korsakoff Syndrome, exacerbated by a lack of proper nutrition, and resulting in permanent brain damage, necessitating ongoing care. The commentary discusses how biases associated with medical conditions, such as obesity and its treatment, can lead to poorer outcomes, as well as strategies to continually re-evaluate diagnostic reasoning in light of ongoing, intensive management and management reasoning

A 55-year-old man with a history of osteoarthritis and supraventricular tachycardia was admitted the hospital with severe COVID-19 and required endotracheal intubation and invasive mechanical ventilation. Following transfer to a long-term care hospital (LTCH) for continued weaning from mechanical ventilation, inadequate tracheostomy management protocols were evident, with no specific instructions provided. Subsequently, the patient experienced respiratory distress and cardiac arrest due to a blocked tracheostomy tube, highlighting critical deficiencies in care and communication. The commentary summarizes the risk factors for tracheostomy complications, the importance of tracheostomy tube maintenance and monitoring, and strategies to safeguard tracheostomy tube care during transitions of care. 

A man in his 70s with a past medical history of lymphoma in remission, obesity, hypertension, hyperlipidemia, obstructive sleep apnea, and supraventricular tachycardia presented to the emergency department (ED) after two weeks of nightly chest pain episodes. His primary care physician had ordered laboratory testing, which was unremarkable other than a slightly elevated D-dimer (which was normal when adjusted for age). His physical examination and laboratory tests in the ED were normal and he had a record of normal stress testing from two years prior. The patient was discharged from the ED the same day but passed away at home two days later due to severe coronary artery disease. The commentary discusses the varied presentation of unstable angina, use of appropriate evaluation and risk stratification, as well as organizational strategies to facilitate thorough patient evaluation across multiple providers, such as standardized patient handoff methods. 

A 57-year-old man was rushed to the Emergency Department from a nursing facility, struggling to breathe. With a history of hypertension, diabetes, and heart failure, his vital signs were concerning, showing high blood pressure, rapid heart rate, and low oxygen levels. Examinations revealed fluid buildup in his lungs and legs, indicating severe heart and kidney problems. Despite attempts to remove excess fluid with medication, dialysis became necessary. However, a complication arose during catheter insertion, requiring emergency surgery to retrieve a misplaced guidewire.

A 77-year-old man was admitted for coronary artery bypass graft surgery with aortic valve replacement. The operation went smoothly but the patient went into atrial fibrillation with hypotension during removal of the venous cannula. The patient was shocked at 10 Joules but did not convert to sinus rhythm; the surgeon requested 20 Joules synchronized cardioversion, after which the patient went into ventricular fibrillation and was immediately and successfully defibrillated with 20 Joules. While the patient was being transferred to his gurney, the operating room team noticed that the electrocardiogram cable that enables synchronized cardioversion was only connected into the anesthesia monitor and was never connected to the patient’s defibrillator. The commentary discusses the risks of unsynchronized shocks or pacing , the role of standardized processes to ensure that operating room equipment is prepared and set-up correctly, and the importance of operating room team preparation to urgently address life threatening complications

An elderly patient residing in a group care home, requiring assistance with all activities and having a history of autism-spectrum disorder, experiences fecal leakage issues despite daily medication. During a weekend shift with reduced staffing, a certified nursing assistant (CNA) discovers the patient soiled in bed, necessitating a shower. While attempting to assist the patient, another bowel accident occurs, leading to a fall and head injury when the CNA calls for help. With limited staff available, the patient is eventually taken to the hospital for suturing and further evaluation, where it's determined she requires a higher level of care due to hazardous conditions in the bathroom. The commentary discusses the challenges in providing adequate care in group home settings, especially during weekends with reduced staffing levels.

A 26-year-old man presented to the emergency department (ED) with abdominal pain, displaying tachycardia and extreme agitation. Despite negative findings on physical examination and laboratory tests, his aggressive behavior escalated, necessitating physical and chemical restraint for the safety of both himself and ED staff. The ED physician verbally ordered 10 mg of intramuscular haloperidol, but the primary nurse overrode the automated dispensing unit and mistakenly pulled a vial of midazolam 10 mg instead of haloperidol. Flumazenil was subsequently administered to reverse benzodiazepine toxicity, and the patient recovered without further complications. The commentary discusses best practices to promote safe medication administration in the context of verbal orders and medication overrides.

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Public Health

As a nurse faces prison for a deadly error, her colleagues worry: could i be next.

Brett Kelman

RaDonda Vaught, with her attorney, Peter Strianse, is charged with reckless homicide and felony abuse of an impaired adult after a medication error killed a patient. Mark Humphrey/AP hide caption

RaDonda Vaught, with her attorney, Peter Strianse, is charged with reckless homicide and felony abuse of an impaired adult after a medication error killed a patient.

Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient and somehow overlooked signs of a terrible and deadly mistake.

The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. But Vaught accidentally grabbed vecuronium, a powerful paralyzer, which stopped the patient's breathing and left her brain-dead before the error was discovered.

Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became "complacent" in her job and "distracted" by a trainee while operating the computerized medication cabinet. She did not shirk responsibility for the error, but she said the blame was not hers alone.

"I know the reason this patient is no longer here is because of me," Vaught said, starting to cry. "There won't ever be a day that goes by that I don't think about what I did."

Shots - Health News

Former nurse found guilty in accidental injection death of 75-year-old patient.

If Vaught's story had followed the path of most medical errors, it would have been over hours later, when the Tennessee Board of Nursing revoked her license and almost certainly ended her nursing career.

But Vaught's case is different: This week, she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, the 75-year-old patient who died at Vanderbilt University Medical Center in late December 2017. If convicted of reckless homicide, Vaught faces up to 12 years in prison.

Prosecutors do not allege in their court filings that Vaught intended to hurt Murphey or was impaired by any substance when she made the mistake, so her prosecution is a rare example of a health care worker facing years in prison for a medical error. Fatal errors are generally handled by licensing boards and civil courts. And experts say prosecutions like Vaught's loom large for a profession terrified of the criminalization of such mistakes — especially because her case hinges on an automated system for dispensing drugs that many nurses use every day.

The Nashville District Attorney's Office declined to discuss Vaught's trial. Vaught's lawyer, Peter Strianse, did not respond to requests for comment. Vanderbilt University Medical Center has repeatedly declined to comment on Vaught's trial or its procedures.

Vaught's trial will be watched by nurses nationwide, many of whom worry a conviction may set a precedent — as the coronavirus pandemic leaves countless nurses exhausted, demoralized and likely more prone to error.

Janie Harvey Garner, a St. Louis registered nurse and founder of Show Me Your Stethoscope , a nurses group with more than 600,000 members on Facebook, said the group has closely watched Vaught's case for years out of concern for her fate — and their own.

A Doctor Confronts Medical Errors — And Flaws In The System That Create Mistakes

Garner said most nurses know all too well the pressures that contribute to such an error: long hours, crowded hospitals, imperfect protocols and the inevitable creep of complacency in a job with daily life-or-death stakes.

Garner said she once switched powerful medications just as Vaught did and caught her mistake only in a last-minute triple-check.

"In response to a story like this one, there are two kinds of nurses," Garner said. "You have the nurses who assume they would never make a mistake like that, and usually it's because they don't realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda."

As the trial begins, Nashville prosecutors will argue that Vaught's error was anything but a common mistake any nurse could make. Prosecutors will say she ignored a cascade of warnings that led to the deadly error.

The case hinges on the nurse's use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. According to documents filed in the case , Vaught initially tried to withdraw Versed from a cabinet by typing "VE" into its search function without realizing she should have been looking for its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger swath of medications, then searched for "VE" again. This time, the cabinet offered vecuronium.

Vaught then overlooked or bypassed at least five warnings or pop-ups saying she was withdrawing a paralyzing medication, documents state. She also did not recognize that Versed is a liquid but vecuronium is a powder that must be mixed into liquid, documents state.

Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to "look directly" at a bottle cap that read "Warning: Paralyzing Agent," the DA's documents state.

The DA's office points to this override as central to Vaught's reckless homicide charge. Vaught acknowledges she performed an override on the cabinet. But she and others say overrides are a normal operating procedure used daily at hospitals.

While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said that at the time of Murphey's death, Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital's electronic health records system.

Murphey's care alone required at least 20 cabinet overrides in just three days, Vaught said.

"Overriding was something we did as part of our practice every day," Vaught said. "You couldn't get a bag of fluids for a patient without using an override function."

Overrides are common outside of Vanderbilt, too, according to experts following Vaught's case.

Michael Cohen, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, past president of the American Association of Nurse Attorneys, each said it is common for nurses to use an override to obtain medication in a hospital.

But Cohen and Brown stressed that even with an override, it should not have been so easy to access vecuronium.

"This is a medication that you should never, ever, be able to override to," Brown said. "It's probably the most dangerous medication out there."

Cohen said that in response to Vaught's case, manufacturers of medication cabinets modified the devices' software to require up to five letters to be typed when searching for drugs during an override, but not all hospitals have implemented this safeguard. Two years after Vaught's error, Cohen's organization documented a "strikingly similar" incident in which another nurse swapped Versed with another drug, verapamil, while using an override and searching with just the first few letters. That incident did not result in a patient's death or criminal prosecution, Cohen said.

Maureen Shawn Kennedy, the editor-in-chief emerita of the American Journal of Nursing , wrote in 2019 that Vaught's case was "every nurse's nightmare."

In the pandemic, she said, this is truer than ever.

"We know that the more patients a nurse has, the more room there is for errors," Kennedy said. "We know that when nurses work longer shifts, there is more room for errors. So I think nurses get very concerned because they know this could be them."

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. It is an editorially independent operating program of KFF (Kaiser Family Foundation).

• criminal case

5 Interesting Medication Case Reports - Part 5

This article highlights 5 published case reports that document accidental administrations of medications following pharmacy or nursing errors.

This article is part 5 of a 6-part series on interesting and unusual medication-related case reports. For part 4 click here .

Case reports are defined as the scientific documentation of an individual patient. These reports are often written to document an unusual clinical presentation, treatment approach, side effect, or response to treatment. Most experts see case reports as the first line of evidence in health care, which can sometimes lead to future higher-level studies.

Case reports can be a great learning opportunity for both pharmacists and pharmacy students to understand a case progression and the unconventional response and effects of medications.

1. Patient harm following Norvasc error 1

Norvasc (amlodipine) is a dihydropyridine calcium channel blocker indicated for the treatment of hypertension and coronary artery disease. A case report was published in 2016 detailing an alarming and overlooked medication error involving a prescription for Norvasc.

The case report involves a recently widowed 71-year-old female who was hospitalized for uncontrolled hypertension and acute kidney injury. During the hospital stay she received temporary hemodialysis, her blood pressure medications were adjusted, and she subsequently improved clinically. Upon discharge her prescription medications included Norvasc 10 mg twice daily, metoprolol 50 mg twice daily, doxazosin 2 mg daily, and torsemide 30 mg daily.

Over the next several months, she began experiencing worsening fatigue, slow movements, personality changes, and uncontrolled blood pressure. During this time, she was hospitalized once for chest pain and had several visits to her outpatient family physician where she was diagnosed with anxiety and depression; for these she was prescribed citalopram and alprazolam. Soon after, she was rehospitalized following a fall due to light-headedness.

An admission medication reconciliation revealed that the patient was actually taking Navane (thiothixene), an antipsychotic, instead of the Norvasc. Upon further review, it was revealed the pharmacy had accidently dispensed the wrong medication despite the written prescription being fully legible. After the thiothixene was discontinued, the patient’s clinical status improvement. The authors explain how this example shows the ‘Swiss Cheese Model’ of how medication errors can occur despite interacting with multiple areas of the health care system.

2. Rythmol prescription error 2

Rythmol (propafenone) is a class 1C antiarrhythmic drug that was FDA approved in 1989. In 2010, a case report was published documenting a medication error involving a handwritten prescription for Rythmol.

The case tells the story a 73-year-old man with a history of cardiac arrhythmia who presented to the clinic for a routine follow-up visit. After being evaluated by his physician, the patient received a handwritten prescription for Rythmol 150 mg, which he had been taking for the previous 3 years. He filled this prescription with the clinic pharmacy and subsequently started to experience nausea, sweating, and an irregular heartbeat. After 2 weeks of symptoms, he called his physician for an appointment, noting that his Rythmol tablets looked different than last time.

Upon evaluation, the physician discovered that the patient incorrectly received Synthroid (levothyroxine) 150 mcg from the pharmacy instead of the prescribed Rythmol 150 mg. The pharmacist who filled the prescription attributed the error to unclear handwriting on the prescription copy. The patient’s symptoms were believed to be caused by both abrupt discontinuation of Rythmol and unnecessary use of Synthroid at a high initial dose. Once the error was corrected, the patient’s symptoms gradually resolved.

The authors explain that this error demonstrates the importance of pharmacists clarifying with physicians on prescriptions with sloppy or illegible handwriting and appropriately counseling patients on new medication therapy.

3. Accidental administration of epinephrine instead of midazolam 3

Medication errors within the inpatient setting can have severe consequences on patient harm and prolonging length of stay. This 2016 case report details a 50-year-old women who was accidentally administered epinephrine instead of midazolam during colonoscopy prep.

The patient originally presented to the hospital with a history of abdominal pain and altered bowel habits. A colonoscopy was scheduled following administration of what was believed to be midazolam 5 mg. She then started to complain of chest tightness, difficulty breathing, and generalized tremors. It was soon discovered that a medication error occurred and the patient was instead administration 0.25 mg of epinephrine instead of midazolam. The procedure was postponed for several days until the patient recovered.

A root cause of the error revealed that the epinephrine ampule was mistakenly placed in the box with the midazolam in the pharmacy following an instance where a previous patient did not require the medication. Ampules of both medications were similar in size, shape, and color. As a result, the hospital initiated new procedures to ensure regular reviews of drug containers and their contents and double checking medication names before administration.

4. Unintentional administration of insulin instead of influenza vaccine 4

In 2016, researchers published the results of an investigation where a cluster of 5 adult patients unintentionally received insulin instead of the influenza vaccine. The mix-up occurred at a public school clinic in Missouri and was discovered following an investigation from the Saint Louis County Department of Public Health. Officials learned that a school nurse inadvertently administered Humalog U-100 insulin instead of the influenza vaccine. Acute hypoglycemia was reported in all 5 patients who received the insulin with varying degrees of symptoms.

After the first 2 patients complained of sweating and lightheadedness, the nurse reported the incidents to the supervising nurse, but did not stop administering vaccines. Two later patients would require hospitalization for their symptoms, one of which was documented to have a blood glucose level of 23 mg/dL. The investigation revealed that the influenza vaccine vial was kept in the nurse’s office refrigerator along with a 10 mL vial of Humaog U-100 insulin; they were found to not be stored in separate, labeled containers or bins. The manufacturer of the influenza vaccine conducted its own analysis but found no deviations or manufacturing incidents that would suggest a quality control problem.

The study authors state this incident was likely a result of ‘confirmation bias’ where a healthcare worker may rely on familiar cues, such as the shape, colors, and markings on a vial to confirm preconceptions, which may lead to reduced vigilance and an increased risk of medication errors.

5. Warfarin and Xarelto duplication 5

Coumadin (warfarin) and Xarelto (rivaroxaban) are anticoagulants used to reduce the risk of stroke and embolism in patients with atrial fibrillation and for prophylaxis of deep vein thrombosis (DVT). A case report was recently published documenting a patient who unintentionally received both medications concurrently.

The case involves a 62-year-old man who was referred to a pharmacist-managed anticoagulation clinic for follow-up post bilateral pulmonary embolism. The patient was advised to continue on the warfarin he initiated in the hospital at a dose of 5 mg daily and return the following week for a repeat INR test. At next visit, his INR was revealed to be over 8.0. He denied taking any extra warfarin doses, recent alcohol intake, or new prescription medications. No symptoms of bruising or bleeding were noted. Upon further questioning, the patient reported starting a new medication 5 days earlier from his retail pharmacy which the clinic determined to be Xarelto 20 mg.

Investigation into the issue revealed that a prescription for Xarelto had been sent to his retail pharmacy to inquire about the cost of the medication with his insurance plan. The retail pharmacy then placed the medication on hold rather than discontinue the order entirely like the clinic staff had requested. When he visited his retail pharmacy the next day, they filled and dispensed the medication. The patient had not been counseled and assumed it was a new medication for his neuropathy. The Xarelto was subsequently discontinued and the warfarin dose was gradually reduced until the INR was within range. The case shows the importance of counseling patients on new medications and inquiring about potential duplicate therapies.

References:

• Da Silva B, Krishnamurthy M. The alarming reality of medication error: a patient case and review of Pennsylvania and National data. J Community Hosp Intern Med Perspect . 2016;6(4):10.3402/jchimp.v6.31758. doi:10.3402/jchimp.v6.31758.
• Devine B. Bad Writing, Wrong Medication. AHRQ. April 2010. Available at: https://psnet.ahrq.gov/webmm/case/215/bad-writing-wrong-medication
• Gado A, Ebeid B, Axon A. Accidental IV administration of epinephrine instead of midazolam at colonoscopy. Alexandria J of Med . 2016;62(1). doi:10.1016/j.ajme.2014.11.003.
• Clogston J, Hudanick L, Suragh TA, et al. Unintentional administration of insulin instead of influenza vaccine: a case study and review of reports to US vaccine and drug safety monitoring systems. Drugs Ther Perspect . 2016. 32: 439. doi:10.1007/s40267-016-0333-2.
• Fusco JA, Paulus EJ, Shubat AR, Miah S. Warfarin and Rivaroxaban Duplication: A Case Report and Medication Error Analysis . Drug Saf Case Rep . 2015 Dec;2(1):5.

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