Analysis of an academic medical center’s corrective action plan in response to fatal medication error using the Institute for Safe Medication Practices’ hierarchy of effectiveness

Summary

Neuromuscular blocking agents (NMBAs) are high-alert medications that require special handling and a robust process that prevents medication error and ultimately protects patients from harm. One patient at a large academic medical centre (AMC) was given vecuronium, a NMBA, instead of midazolam, and died as a result. The medical centre was tasked by the Centers for Medicare & Medicaid Services to make a list of actions to prevent a similar incident happening again. This study in Patient Safety analysed the medical centre's corrective action plan in comparison to the Institute for Safe Medication Practices’ hierarchy of effectiveness of risk-reduction strategies.

The authors found that 76% of strategies in the plan were of low leverage, 16% were of medium leverage and 8% were of high leverage. They argue that the action plan should have included more system-based interventions, which include medium- or high-leverage strategies, rather than relying heavily on initiatives dependent on human action. Despite the lack of these systemic tools, CMS granted approval for the plan. The authors suggest that overlooking these systemic tools may amplify patient harm and negatively impact workforce satisfaction and efficiency.

In addition, they highlight that the absence of a “just culture” also plays a role in patient harm. Recognising that medication errors in healthcare are usually attributed to human error highlights the importance of fostering a just culture that advocates for system accountability to enhance patient safety.