My Near Miss

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.

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.

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 through ISMP-MERPS to help protect your colleagues and their patients.

At the very least, please take our survey and stop back often to see what stories are being told.

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.

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Chuck DiTrapano RPh

Chuck DiTrapano RPh

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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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