QI Presentation: Right Place, Right

Drug, Wrong Strength

Shannon Orr, Iskra Ruiz, Kailey Smith, Preetpal Virk
Background
● 2 year-old female admitted for a 10% total body surface area burn
● Treatment: Oral acetaminophen & PRN NSAIDs for pain
● Dressing changes every 3 days- oxycodone administered prior
● After a dressing change, patient was lethargic, difficult to arouse, and had shallow breathing
● Discovered the automated dispensing machine had a higher concentration of oxycodone solution than what
was normally there
● Patient received nearly 5x the ordered dose, naloxone was administered as treatment
● Intubation was avoided and her breathing quickly improved
● Monitored for a week in the hospital and safely discharged
Fishbone Diagram
Manpower Machines

Pharmacist misplacement Improper labeling on dispensary

No barcode scanner
Nurse not checking Drug overdose

No me checks
Lack of packaging & coloring
differentiation
Inadequate assessment

No barcode scanning Different location for different doses

Methods Materials
Root Cause Analysis
● The incorrect placement of medication in the automated dispensing machine and a
lack of medication checks led to the incorrect dosage administration, resulting in a
medication overdose.
Actions to prevent further occurrence
● Barcode system will be implemented by pharmacists for drug receiving, storage, preparation, dispensing, and
by nurses in patient care areas for drug retrieval and prior to patient administration. This will be performed in
the pharmacy and in patient care areas. Implementing a barcode system will help eliminate human error in
medication administration.
○ This action is intermediate as it eliminates potential for human error in most cases, however the nurse or
pharmacists still have potential for overriding an alert, as well as when a specific dose of medication
must be drawn up.
● Pediatric dosages of medications will be provided in standard or ready-to-administer doses by pharmacists
when stocking all medications. This technique will eliminate potential error on the nurses’ end when drawing
up and administering medications.

○ This action is weak as it relies on the pharmacist to make or deliver a ready-to-administer dose.
Although this action will likely reduce variation, it still allows for human error from the pharmacist.
Actions to prevent further occurrence

● Automated dispensing cabinets will be assessed for safety practices with the ISMP Medication Safety Self
Assessment for Automated Dispensing Cabinets on a monthly basis by pharmacists. Regular assessments will
help to prevent machine error.

○ This is an intermediate action as it improves, or prevents error with the equipment needed to do the
process. It also is an action that reduces variation in outcome by ensuring working equipment.
● All hospital staff handling and/or administering medications will be retrained to use medication incident
reports. Feedback from these incident reports will be used to provide feedback, offer solutions, and allow staff
to become more aware of safety in medication administration.

○ This is a weaker action as it is focused on informing the staff and is focused on examining if the process
could be improved or changed.
Actions to prevent further occurrence
● The number of available concentrations of medications will be minimized. When more than one concentration
is needed, explicit labeling (such as bolded dosing and different colored labels), as well as separate or
electronically managed storage will be used. Pharmacists will implement when stocking medications.
Pharmacists will assess during all stockings if various doses are needed. Nurses will be instructed to file safety
reports if more doses than needed are made available. Providing fewer readily available doses will eliminate
potential for administering wrong doses when possible.

○ This is a weaker action because although it does provide action to reduce variation in outcome, the
process of reducing available concentrations is left up to personal interpretation.
Outcome Measures
Numerator: Patients who experienced a medication overdose.

Denominator: Pediatric patients who received medications during their hospital stay.

Threshold: Less than 5% of the pediatric patients will have a medication overdose.

Date/Timeframe: The outcome will be measured for duration of 3 months.

Outcome Measure Type
Adverse Event Outcome: Three months following the implementation of the barcode scanner and random checks of medication
placement in dispensing machine, the incidence of medication overdose on pediatric unit will be reduced by <5%. The numerator will be
the number of patients that experienced medication overdose.

Root Cause Outcome: Random checks by the charge nurse on the medications in the dispensing machine will be done each week for
three months. Less than 5% of incidence will occur with medications being in the wrong compartment.

Action/Process Outcome: Ninety-five percent of nurses will give an appropriate reason overriding dosage amounts on the computer;
which can be assessed by checking the history on the MAR system.
Stakeholder Analysis
Internal (unit) stakeholders External stakeholders
Hospital employees: ● Local businesses
● Insurance companies
● Nurses
● Community leaders
● Physicians
● Unions
● Pharmacists
● Professional organizations
● Patients
● Patients families
● Board of directors
Force Field Analysis
GOAL: Reduce or have No Medication Errors
Forces driving to reach goal
Forces restraining from reaching the
● Supportive and willing internal goal
hospital staff and a culture that
supports change to improve
● Denial in responsibility
patients safety
● Fatigued and low energy levels in
● Positive and receptive attitudes nurisng or medical staff resultig in
to improve and change protocols
to avoid medical errors. Ex: ● Negative attitudes towards training
Pharmacist willing to change and and new protocols
undergo training to add
additioanl checkpoints/protocol.
References
Valentina, J., & Greenall, J. (2018). Right place, right drug, wrong strength. Patient Safety Network. Retrieved
from: https://psnet.ahrq.gov/webmm/case/436/right-place-right-drug-wrong-strength

VA National Center for Patient Safety RCA Tools (2015). Root Cause Analysis Tools: VA national center for
patient safety. Retrieved from:
https://sakai.apu.edu/access/content/group/ad74f7a8-849c-41b4-86c0-4f3553a8b8d2/Document%20Sharing/Quality
%20Improvement%20Project%20Resources/VA%20RCA%20tool%202015.pdf