An oncology patient post-chemotherapy came into the ED a week prior with fevers, rigors, and neutropenia. I admitted her to our GIM service from ED and started her on broad spectrum antibiotics as per the febrile neutropenia protocol that we use there. Five days later, her cultures (blood and urine) had not grown any bacteria, and despite the antibiotics she was still having fevers and felt terrible.
According to our febrile neutropenia protocol, she should be started on antifungal treatment now, and the drug of choice as per that protocol is amphotericin B (affectionately known as "amphoterrible" by the oncology nurses). The reason we call it amphoterrible is because the side effects related to this drug are sometimes as bad as the symptoms of infection. Because of this, we always order it with hydration and premedication.
I ordered the amphotericin B through the computer into our most wonderful online order system and ordered the prophylactic IV hydration and premeds on a paper order sheet since those particular therapies were not part of the online ordering system and this is how it's done. Anybody see the disaster about to happen here?
Yes, you guessed it: she had a horrible reaction! In review, we found the patient received the amphotericin, but no one gave her the hydration or the premedications because the two orders were not together and the person completing the order didn't put the two together. I told the patient what had happened and requested an incident report be completed.
Several months later, the exact same scenario happened to a gentleman who was also suffering from febrile neutropenia and started on amphotericin B. Again, I informed the patient and asked that an incident report be completed.
The next time I ordered amphotericin B, I decided to be proactive: I informed the nurse about the premedications and hydration. In addition, I told the patient, and I told the charge nurse. I went home feeling I had done an excellent job of communicating and was certain everything would be fine... trouble was, this time they forgot to give the amphotericin!
Incident report #3 was requested, and I sensed the nurses were starting to resent me. I was approached by the pharmacist who was just as frustrated as I was, but while we were discussing it, I said to him, "This has happened three times that I know of; I don't think we can blame the nurses. The system for ordering this particular medication is obviously flawed. Three different nurses, three different times have made similar medication errors. I think it's because we have the orders for the therapy in two different places. We don't need to address this through the nurses. We need to change the system!"
I have to tell you, all of my interactions with pharmacists have been positive, and this particular pharmacist was no exception. He completely agreed with me. Together we lobbied for a change. We advocated that the whole order should be parceled within the online order system so that nurses saw the premedication, hydration, and amphotericin as a package. At first, we were told it couldn't be done and were presented with all kinds of potential work-arounds, but we persisted and used patient safety literature and the examples above to support our request.
It took a while to change that system, but eventually we got it changed, and I haven't heard of a similar error since.
The moral of the story? Human errors are often related to systems issues. By reviewing errors, we take a step back and can see the big picture, and see whether there is a way to make the process safer for everyone by changing something in the system, rather than focusing only on the mistake of an individual.