Fatal Errors

Maria Herbas

Wilmington University
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FATAL ERRORS

Fatal Errors

The issues within case study 2.1, involved many different parties. There wasn’t just a

single party that was responsible for the overdosing of the infant. As described in the textbook,

there is a system that takes place for different protocols that involve people, policy, and process.

In this case study, there were errors in all three areas of the system. I believe some of these errors

could have been avoided if they were addressed properly.

Some of the issues that occurred in the people, policy, and process components includes

the lab tech not taking action to investigate the high sodium levels of the child. This would be an

example of a people issue since the tech did not take the appropriate plan of action. This could

also be a policy error if the tech didn’t have a set protocol to follow when something like this

occurs. The mistake the pharmacy tech made with entering the wrong amount of sodium chloride

would be both a process and people issue. The process/technology issue would be that, according

to the case study, there is not a confirmation page that verifies the amount being entered and

there should be especially if distributing a larger amount than the norm. A policy issue I depicted

in the case was the IV bag not having the appropriate labels, and if there are too many labels why

there isn’t a way to condense the number of labels.

There were other issues that could be described, but I believe these stood out the most.

The hand-offs between each process was not handled with efficient and effective

communication. The interactions were more with technology than verbally communicating with

one another. Unfortunately, the lack of double-checking, communication, and appropriate

protocol is what I believe resulted in the death of the infant.

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Typically when a facility experiences a scenario similar to the one in the text, there is a

need to ensure this does not happen again. For one of the issues I explained, where the lab

technician did not investigate the high sodium levels, there should be stricter protocol for the lab

technician to report the error and either tell their supervisor or run another test. Although it may

be easier to blame technology, it is important healthcare workers always double check their work

manually, if possible. In addition to incorporating a stricter protocol, a different software that can

catch data entry errors and other errors to prevent the death of a another infant. It may be that this

software is not available to facilities at this time, but there is a methodology that could guide the

facility in the right direction.

There are different methodologies that health care facilities have adopted to provide

improved workflows and processes. Although most adaptations could see improvements, there is

one that would provide the most improvement. It is a combination of two methodologies called

Lean Six Sigma, Lean Six Sigma focuses on process flow and process variation (Amatayakul,

2012). This method provides process analysis for improvement but also incorporates the need for

innovation. If Lean Six Sigma were implemented it would have Gemba walks to make sure

procedures are running smoothly on a regular basis, and there would be more direction given

from leadership to answer if a protocol needs more attention.

Overall, there are many ways to improve the errors seen in this case study and with the

right guidance from executive leadership and process management it can prevent an unnecessary

death to occur.
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References

Amatayakul, M. (2012). Process Improvement with Electronic Health Records. Taylor & Francis

Group.