HSIB report: Inadvertent administration of an oral liquid medicine into a vein (April 2019)

Dear Patient Safety Learning,

Inadvertent administration of an oral liquid medicine

into a vein (12017/009) HSIB.

PSL over view: Healthcare Safety Investigation Branch (HSIB) report on the inadvertent administration of an oral liquid medicine into a vein. This report indicated the importance of using human factors in the investigation process. The investigation reviewed the effectiveness of the current processes for the storage of medicines, equipment design, and the prescribing, preparation, checking and administration of medication. It also considered the contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein. The effectiveness of current processes for implementation of local safety standards for invasive procedures was also considered. A human factors expert was involved in the investigation and a dedicated report was written based on the evidence reviewed, a reconstruction of the event and a simulation of what should have happened.

The global hospital latent-error: This HSIB report has missed a massive industrial faux-par and Ward-Patient Safety Solution HSIB 14.1.2021..pdfpartly responsible for 2.6 million unnecessary healthcare deaths annually in the Sector.

Hospital management has no “Alarmed Error Recovery Protocol (1)” preventing

medicine error, missed procedures and error cascade across departments.

This HSIB report (12017/009 ) should be withdrawn and updated. You can read the system-solution from the Wexler Medical Centre in reference (2) and enclosed PDF. Are there similar solutions here in the UK? The next HSIB report on paracetamol overdosing will almost certainly be read by Police Operation Magenta (450 opioid deaths).

Thank you.

Kind Regards

Derek.

References:

(1) The Blame Machine. R B Whittingham. ISBN 0-7506-5510-0.  Industrial H&S. https://books.google.co.uk/ then type “5.3 error recovery ” (page 74 to 79). Compelling feedback reduces HE consequences by a factor of 10,000+.

(2) Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors: J. Bonkowski et al. AEM Vol. 20.8: p801-806: 2013. (Method: pdf page 802, 2nd column, "Medication administration with BCMA................. an alert notified the nurse of a potential for error".