As outlined in the Canadian Patient Safety Institute’s Forward with Four strategy, medication safety in a top priory for patient safety in Canada. When looking through Global Patient Safety Alerts, there emerges a common theme, among many others, of verbal prescribing or verbal orders contributing to errors in medication dosing.
In Wrong Dosage of Drug Due to Incomplete Verbal Instruction from the Japan Council for Quality Health Care, two patient safety incidents are discussed where the patient received the wrong dose (a high alert drug in one case) due to ineffective verbal communication of the drug order. Both incidents involved a verbal order using the term “milli” which resulted in confusion between “milligrams” and “millilitres”.
In a similar “What do they mean?” vein, the Pennsylvania Patient Safety Authority produced “Give 40 of K” (You Know What I Mean, Don’t You?) and discussed the hazards of verbal orders and uses examples of mix ups with potassium (KCl), a high alert drug, to illustrate the point.
Closer to home, the Institute for Safety Medication Practices Canada has produced a Safety Bulletin: Reported Error with Sodium Chloride 3% Reminds Us of the Need for Added System Safeguards that outlines a need for additional safeguards when using intravenous (IV) hypertonic sodium chloride (saline) solutions. The bulletin describes a patient incident involving 3 per cent sodium chloride IV and the dangers of stocking 5per cent sodium chloride IV. In a Canadian hospital an order for 250 mL 3per cent sodium chloride IV solution was written at night and required a return to the hospital by the on-call pharmacist. The pharmacist delivered the product to the nursing unit with verbal instructions as to the patient name. The sodium chloride 3 per cent solution was then mistaken for a premixed heparin solution and was administered to the wrong patient.
Medication safety incidents happen with frequency around the world, and there are currently 365 alerts and advisories contributing organizations in the Global Patient Safety Alerts database. From these alerts and advisories come 2,291 recommendations for their prevention. Do you have medication incidents occurring in your facility? Use Global Patient Safety Alerts to help prevent their reoccurrence and become a contributing organization to share your stories and solutions and help others who are struggling with problems that you have already solved.