Drug Administration

A hospital in Nashville recently severely injured several patients when they administered potassium phosphate in place of the anesthetic Polocaine. In order to understand how this happens, it’s important to understand how medications are given in a hospital setting. This is dictated in general terms by the Joint Commission, a U.S. nonprofit organization that sets safety and quality rules for hospitals and medical centers. In order to be certified, one has to conform to the rules and guidelines of the Joint Commission. The commission inspects every hospital every three years, and will also inspect a hospital if they have had sentinel events. Here is generally how medication administration goes:

• When the patient checks in to the facility, they ae identified by multiple identifiers, including name, date of birth, address, and others. This ensures the hospital knows which person they are dealing with. A wrist band with a barcode matching the patient’s record is placed on the patient’s wrist.
• The intake nurse reviews medication allergies, current medications, and medical history with the patient.
• In many cases, a pharmacy representative will repeat the verification process.
• The provider orders the medication that will be given.
• The hospital’s computers check to make sure the medication is proper, and there are no contraindications for the medication. If it finds any, it will alert the provider to the issue, but the provider can override this recommendation.
• A pharmacist reviews the patient’s record and the medication order to ensure the order is proper, the dose is correct, and the patient has nothing that will contraindicate this medication. It’s then released. Sometimes, the medication has to be mixed in the pharmacy. There are complex procedures for doing this as well, with numerous safeguards in place. Still, mistakes DO happen.
• The nurse who will administer the drug pulls the medication from the drug cabinet, which is locked and keyed to the nurse’s fingerprint and the patient’s name. Doctors do not have access to this system, only nurses and the pharmacy can open the cabinet.
• In case of emergency, if the pharmacist hasn’t approved the medication, or a provider hasn’t ordered it, some nurses can override this and pull out a medication that hasn’t been ordered. Sometimes it requires a second nurse to also use their fingerprint to access the medication. Each unit has its own rules as to who can do this. The nurses in the ED, ICU, and other high acuity units have more latitude than do nurses from other units.
• Some medications are marked with brightly colored bands that say “high risk medication” as a visual warning that the drug can be particularly dangerous if given improperly. In those cases, two nurses are required to administer the medication, to further reduce the chance of error.
• The nurse then uses a computer at the patient’s bedside to scan their wristband to positively identify the patient. A prudent nurse will also ask the patient their name, date of birth, and which medications the patient is allergic to.
• Then the nurse scans the barcode on the medication, and at this time, the computer matches what was ordered and approved to what was just scanned. If there is a mismatch, the screen gives a bright red warning overlay, telling the nurse that there is a problem.
• As a final check, the nurse administering the medication is expected to check the medication, dose, route, and other facts to ensure the drug is safe and proper for that patient before they actually administer it.

All of this is designed to minimize the chances of a medication error, but there are numerous places where someone can take shortcuts and the result is a patient getting the wrong drug. In the case of Polocaine, it is administered by a nurse anesthetist or doctor. It can be pushed in manually, or can be given by an automated pump- in both cases directly into the spine.

Although I have no direct knowledge of this specific incident, here is what I suspect happened. The hospital says it was a pharmacy error. In the pharmacy, Pharmacists or certified techs prepare it inside a sterile, laminar-flow hood to ensure complete sterility. The ingredients to be mixed are placed on a table and photographed for later tracking. A second person (usually a licensed pharmacist) then checks the medication to ensure it is correct. They are then mixed, a tracking tag with a barcode are placed on the medication, and it is sent to the point of use. With some medications that are high risk, more than one person is required to sign off on the blend to ensure there were no mistakes.

It seems likely the pharmacist or tech who mixed the drug put the potassium phosphate in the medication instead of the Polocaine, and the person whose job it was to check it just signed off on it without looking. People tend to make these sorts of mistakes when they are overloaded with tasks. I’ve had this mistake happen three times in my career, and each time I caught the error before I gave it to the patient. Once was with half normal saline being confused for normal saline, the second was a unit of packed red blood cells that were not properly matched, and the third was a bag of phenobarbital that was improperly mixed. The mistake with the phenobarbital was unusual, as it was the hospital’s computer that made the error, and a subsequent investigation showed this error was system wide, with hundreds of patients receiving the incorrect medication. I was just the first person to catch it. It seems likely that some patients experienced negative consequences, although no one can really know for sure.

Administering medications is one of the riskiest things a hospital does. A busy hospital gives medications millions of times per year. Every step and precaution is taken, but no policy or procedure is 100% foolproof. This is why medical careers like nursing, pharmacy, doctor, and others have such high barriers to entry and licensure. We could have cheaper healthcare by lowering those barriers and creating more licensed personnel, but we do so at higher risk of errors.