Medication Errors: My Near Miss

Medication Errors: My Near Miss Cover Image
RxToolKit Founder Chuck DiTrapano shares his close-call with a medication error, what he learned from the experience, and resources for reporting errors or near-misses.

About 6 years ago I was working as the IV pharmacist on second shift and I was presented with a large number of IV’s to check prior to delivery.

The IV delivery to the nursing units was already late and I felt the pressure to get the IV’s checked as fast as possible. I was checking the lot of IV’s at a speed that I thought safe.

The Close Call

A pharmacist checks an IV bag.I checked one IV for D5W 1,000 mL with 50 mEq of sodium bicarbonate. As I checked it, I put my initial on the label and then moved on to the next IV. Something, and I don’t know what, caused me to stop and re-look at that IV one more time. I checked everything again and suddenly realized that the technician had injected 50 mL of potassium acetate 2 mEq / mL in the bag instead of 50 mL of sodium bicarbonate.

It is still difficult today to articulate how I felt at that moment. I was very close to physical illness. I don’t know what happened to make me look at that IV again, but I am so thankful that I did. I think about that incident whenever I think about Eric Cropp’s story.

I am fortunate to work in a hospital that has shown it lives by a just culture. I have witnessed personally how they have approached incidents and they do all they can for the patient, the family, and the caregiver.

Eric wasn’t so lucky. I know him and I know how difficult it is for him to live with the consequences of the error. I admire him so much for doing all he can to help the rest of us in our practice environments.

Reporting Errors

The Institute for Safe Medication Practices (ISMP) operates two national error-reporting programs—the National Medication Errors Reporting Program (ISMP MERP) and the National Vaccine Errors Reporting Program (ISMP VERP). Both are confidential voluntary programs that provide expert analysis of system-based causes of medication and vaccine errors.

Please share your near miss with our readers. It helps to tell the story and it helps the healing process. It can also help the rest of us prevent it from happening to our patients. Report events to help protect your colleagues and their patients.

We are all in the healthcare profession to help our neighbor; certainly none of us wants to do any harm.

Hopefully by sharing our stories, we can help each other and bring awareness to prevention.


Picture of Chuck DiTrapano, RPh

Chuck DiTrapano, RPh

RxToolKit Founder and VP of Pharmacy Education, Chuck DiTrapano, is a pharmacist, seasoned healthcare executive, and military veteran. Before founding RxToolKit, Chuck served in various leadership roles within large healthcare organizations including Vitalink Pharmacy Services and Omnicare. Chuck served as the Operations Manager of Reading Health System’s Pharmacy from 2001 until 2017. At Reading, Chuck was inspired to start RxToolKit as he saw firsthand the need to enhance medication safety through process improvement.

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About RxToolKit

RxToolKit was founded by an experienced infusion pharmacist to act as a virtual pharmacist. RxToolKit’s flagship software solutions include RxWorkFlow and RxELearning which are web-based applications designed to reduce medication errors, enhance clinical competencies, increase patient safety, and improve clinical outcomes.

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