In the book “Patient Safety for Health Professionals”, it states, “While I worke

Question

In the book “Patient Safety for Health Professionals”, it states, “While I worked as a dental assistant, I learned a lot about what goes on “behind the scenes” in a dental office. I do not think this office was unusual. There was drama, frustration, and a lot of work that needed to get done. Most of us had multiple duties every day. For example, the manage might double as an assistant if we were in a bind, or an assistant might take over the managerial duties and have to order supplies. Temporary employees, both dentists and assistants, were called in all the time, and some sort of change always seemed to be being made to the organization of the office. One day, all of this confusion almost led to a mistake. A patient came in with high blood pressure, which is not unusual for people who are about to have numerous procedures done. Although she was on medication, her blood pressure was still very high; thus, we decided to give her some time to calm down. I told her that we were going to wait a little while until her blood pressure went down. I brought her a magazine and told her I would be back. When I rechecked it in 15 minutes, it was still high. At this point, the dentist spoke with the patient and asked whether she wanted to continue to wait or reschedule her appointment for another day. The patient chose to wait, so we obliged. During the next hour, the entire staff had to hurry a little more because we had the same number of patients scheduled but one less room to treat them in because of the waiting patient. We were in overdrive mode when we returned to this particular patient. Usually, when a patient is at risk for any type of cardiovascular episode, we use an anesthetic without epinephrine. The dentist asked her assistant to prepare the anesthetic, but the assistant got caught up with another patient who had wandered out of his room. To be helpful, the dentist prepared the injection herself. She did not know, however, that she selected one with epinephrine. A few days earlier, the anesthetic had been ordered from a different company that color coded its vials differently. Usually, the green and red vials were anesthetic with epinephrine, and the blue were without epinephrine. The new company made blue vials with epinephrine. No one had informed the dentist because it was usually the assistants who prepared the injections. The dentist returned to the treatment room and was about to inject the anesthetic when the assistant walked in with her prepared injection. She saw that the dentist had the wrong colored vial, immediately realized the mistake, and simply said, “Doctor, we have an emergency situation and we need your help.” Of course, the dentist left the room without administering the anesthetic. The assistant walked into the dentist’s private office where no one would overhead and explained the situation. The dentist returned to the patient, explained there wasn’t an emergency after all, and gave the correct injection. What would have happened if this patient had received the wrong anesthetic? She was having extensive work done, including extractions, and would have been given several injections at once before we had started doing anything. Fortunately, we never found out.” 1. Describe the contributing factors to the system error in this case. 2. What human factors contributed to the error? 3. What changes would you suggest to make this office a “high-reliability organization?"

Explanation / Answer

1. Describe the contributing factors to the system error in this case.

The contributing factors to the system error in this case are:

Inadequate health worker to patient ratio:

One of the most important factors for medication error is assigning too many patients for a single staff. As a result of this, the staff has more workload. Patient safety and workload of a staff are inversely proportional to each other. That is, if one staff has more work to do, then his patient care is focused to a little extent leading to compromised patient care.

In this scenario, there was only one dental assistant available, and when the dentist was on a procedure, he had to do another work related to patient care. These types of scenarios frequency occur in hospitals and is a major factor for medication error and compromised the quality of care.

Trying to administer medication without reading the drug label:

Assuming the drug with the colour code alone and without reading the label is a major cause of the drug error. Here, the dentist had assumed that blue vials contain epinephrine while this is not the case. If she would have read the label of the drug (which reads the name of the drug), then she had not loaded the injection and risk for medication error would not occur.

2. What human factors contributed to the error?

The major human factor that contributed to the error are:

It should be noted that the Dentist had loaded the medication containing anesthetic with epinephrine instead of anesthetic alone (without epinephrine) by looking at the colour of the vial and not by reading the drug name in the vial. This is a major error. In any circumstances, a health professional should not administer a medication with assumptions. Here, the Dentist had assumed that the colour of the vial differentiates one drug from another (anesthetic and anesthetic with epinephrine). As a result of this assumption, she loaded the unwanted medication leading to medication error.

Moreover, the drug anesthetic with epinephrine is a high-alert medication meaning that the drug has more potential to cause a major harm to patients. The patient would have undergone a serious medication error resulting in bleeding due to the medication and the procedure(s).

The dentist must have been communicated about the changes in the colour of the vial:

There was a regular supply of vials with the same colour for the same type of drugs. However, a few days earlier, the vial colour of the drug was changed leading to the confusion. It was the major responsibility of the dental assistant and other staff to communicate this information to the dentist so that in the absence of any assistants', the dentist could have been cautious while loading the drug.

What changes would you suggest to make this office a “high-reliability organization?"

Measures to increase patient safety:

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