A 46-year-old man has been in hospital with nausea and vomiting that has persisted for 3 days. Another man, aged 58 years, with the same last name (Semple) was admitted at 06.30 to the same six-bedded bay for the treatment of alcohol withdrawal symptoms. The admission occurred at 6:30AM, at about the same time the nursing shift changed.

The second Mr Semple had been prescribed a 2 mg dose haloperidol to be given IV at 07.00 for agitation.

The staff nurse drew up and checked the injection against the prescription with a colleague in the ward preparation room. However, she confused the two patients when she entered the patient bay.

She was about to administer the haloperidol to the wrong Mr. Semple, but the medical student allocated to him was preparing for the consultant ward round and asked the nurse what medication he was about to receive.

When the student informed the nurse that she was unaware that the medical team had ordered any haloperidol for this patient and wasn’t clear about the indication for a sedative, they checked the medication chart together and recognised the error.

The haloperidol was given to the right Mr. Semple, and one Mr. Semple was moved to another room, to reduce the chance of another such error.

• What ‘system’ factors contributed to this ‘near miss’?
• What ‘human’ factors contributed to this ‘near miss’?
• If you were in charge of clinical risk management for the hospital division what recommendations and response would you make to ensure that this event in unlikely to be repeated?

Many thanks to Professor Simon Maxwell for this case. Our first year students will be looking at medication errors in more detail during this week’s teaching.

A 75 year old lady on a medical admissions unit has extreme agitation unresponsive to haloperidol. The specialist registrar decides to follow the local protocol and give her the benzodiazepine sedative lorazepam. The first year doctor in charge of the ward is left to organise the injection after the evening ward round. The doctor is unfamiliar with lorazepam but goes to the ward office and looks up the dose in the British National Formulary, and finds that it is 25 micrograms/kg. He estimates that the patient weighs about 60 Kg. He calculates the dose of the injection with the help of a colleague and prescribes a dose of 15 mg IM. The nursing staff on duty are also unfamiliar with lorazepam but find that they have two 1 mL vials (strength 4 mg/mL) available on the ward so they contact the night sister to ask for help. The night sister asks the staff nurse to go through the calculation with the doctor. They agree that the calculation is correct and contact the night sister. The night sister organises for supplies of lorazepam to be procured from two other wards to enable the dose to be administered. The ward doctor draws up the injection and administers it. The patient’s agitation abates and she is soon asleep.

Around 30 minutes later there is a cardiac arrest in the next door bay where a 66 year old man is successfully resuscitated. While writing up the notes from this event the anaesthetic registrar notices that the first patient has extremely shallow breathing. On further investigation the rate is 6 breaths/min and the blood pressure is only 80/50 mmHg. After learning of the earlier events the patient is administered flumazenil 400 micrograms IV and transferred to the intensive care unit where she makes a recovery.

• How much lorazepam should have been prescribed?
• What ‘system’ factors contributed to this ‘near miss’?
• What ‘human’ factors contributed to this ‘near miss’?
• If you were in charge of clinical risk management for the hospital division what recommendations and response would you make to ensure that this event in unlikely to be repeated?