Author: Leslie W. Hall, M.D.
Title: Associate Professor of Clinical Internal Medicine
Institution: University of Missouri – Columbia
Examine human factors and basic safety design principles as well as
commonly used unsafe practices as they relate to an adverse event in
health care. Describe the benefits and limitations of information
systems in the improvement of health care quality. Discuss effective
strategies to improve medication safety.
Value the balance between professional autonomy and standardization
or reliability. Appreciate the cognitive and physical limits of human
performance. Recognize the value of engaging in root cause analysis
rather than blaming when error or near misses occur. Value relationship
between national patient safety campaigns and implementation in local
Use appropriate strategies to reduce reliance on memory. Demonstrate
an effective use of strategies to reduce risk of harm to others.
Participate appropriately in analyzing errors and designing systems
The attached case describes an adverse event in which
an infant received a potentially lethal overdose of potassium via
intravenous infusion. Although the infant fortunately suffered no
permanent harm from this event, this case affords students an
opportunity to review the many factors that contributed to this serious
error. In reviewing this case, nursing students are challenged to look
beyond blaming one or more health care workers for this mistake, and
instead identify system issues (latent factors) that led to the
environment where such an event could occur. They are then challenged to
identify possible system interventions that might lead to safer systems
of care in the future.
We have utilized this primarily in small group settings (some
single-specialty, some interprofessional), usually in the format of a
simulated root cause analysis. However, this case could also be utilized
for computer-based training.
Learner evaluations of sessions in which this teaching case has been
utilized have indicated that the case was felt to be helpful in learning
important patient safety principles.