It’s more complex than it seems….19 babies received the wrong vaccinations

A week ago there was an incident at one of the private hospitals.  Nineteen new-born babies received the incorrect BCG vaccination and are now at risk for contracting Tuberculosis and suffering other side effects.   According to the media reports, the vaccine was confused with another drug used for a different patient population (adult and new-born) with different indications. But vials are similar in appearance.

No doubt the parents are furious and the media has a duty to report and allow for public comment.  I keep telling myself not to read the comments alas I still read it.  The readers has crucified the nursing staff involved and are blaming the lazy, stupid, can’t read, how-hard-can-it-be-to-do-your-job nurses.   Stupid nurse, fire the nurse.  End of story.  Problem solved.

Errors and failures in complex systems such as hospitals are not that simple.  It is not linear with a direct and clear relationship between cause and effect.  And neither are the interactions between the various functions within the system linear either.   In complex systems there is no single most “fundamental” reason for an error.  There is an interaction of several causal factors originating from various places within the system.  The inquisitive investigator will find patterns between apparently unrelated incidents prior to this incident.

The impact of a blame culture or over simplified cause and effect investigation results in system failures being “blamed” on the last “link” prior to the incident.  This last link is typically the doctor or nurse involved in patient care.

Possible contributing factors to the vaccination error:

  • The drug manufacturers.  There has been an increasing push on manufacturers to distinguish medication and provide visual cues on ampoules as warning prompts.  For instance the difference between medication manufactured for adult, paediatric and neonatal should be visible by either colour or tag.
  • The pharmacist that dispensed the drug had a duty to check and label it.  The question should be asked that if an adult drug ended up in a new-born unit, was there a dispensing error?
  • Responsible person receiving and unpacking the medication in the unit.  This person has to check medication received against requested medication.  The role is performed by an administrator with no nursing background.  If the packaging was familiar and the name similar, they would miss the error or assumed it is a generic.
  • The first nurse to administer vaccination using the vial.  There is policies dictating that nurses perform the 5R’of medication administration to ensure that it’s the right drug, right dosage, right route for the right patient, at the right time.  Was this done, and could the nurse complete the check without interruption?
  • Normalizing deviance.  If the same constraints are experienced on a regular basis it is accepted as normal.  When it’s accepted as a “new” norm it creates an environment where failure or error is inevitable.  Nursing shortages has become normal; this has an impact on safe medication administration practises as well as the frequency of interruptions during this risky time.  This normalizing deviance results in medication error becoming inevitable; the question is simply when it is going to occur, not if.
  • Latent factors includes management decisions, staffing levels, general policy and procedure, design of the unit, the pharmacy and the hospital, staff related factors such as perceived time pressure to perform tasks, fatigue, amount of recent shifts worked, was this an overtime shift, how many hours since the last uninterrupted break.  Level of experience of the nurse, pharmacist, ward administrator.  These latent factors can be dormant in a complex system prior to it causing failure.

Errors involving drugs must be the most common hospital safety event and it has been researched widely.  The high error rate may be because there is an over reliance on human factors with a disregard of heuristics during medication preparation and administration.  We need to avoid relying on the flawed human aspects of decision making.  When making rapid decisions we apply cognitive shortcuts. An example would be reading the first few letters on a familiar looking vial, kept in the normal storage space in a container marked with the vaccine name.  So we make an assumption that this must be the right drug and we continue to the next decision. The innovative safety-vests stating do-not-disturb can reduce the pressure to make rapid decisions before the next interruption.

I certainly felt that I could relate to this incident.  It could’ve been me making the error.  I wish that I could say that I always do rigorous medication checks; or that I trust my own decision-making towards the end of a twelve hour shift with limited breaks.  I wish that I could say that at the end of back to back shifts I’m still as conscientious as during the first shift.  I wish that I could say that frequent interruptions do not affect the task that I’m busy with.

 In summary

According to statistics by the Institute for Healthcare Improvement approximately 5% of medical error and harm is caused by incompetence or negligence.  The other 95% involves conscientious, competent and possibly caring individuals.  Mistakes such as this error were probably caused by a bad system and not a bad healthcare professional.

There is a saying that: “a bad system will beat a good person every time.”

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