A woman in labor was given an epidural of the skin antiseptic chlorhexidine after the container was accidentally switched with that of the epidural drug. According to a neurologist, the lasting permanent damage was small, but the woman was hospitalized for two weeks, reportedly in severe pain.
The incident can be examined in a Cause Map, or visual root cause analysis, which begins by determining the impact to the goals. In this case, the patient safety goal is impacted because of the risk of lasting damage. (The risk is considered small because of the amount that was administered.) This is a “never event”, or event that should never happen in a healthcare facility. The patient services goal is impacted because of the cleaning fluid being administered instead of a proper epidural. The labor/ time goal is also impacted by the investigation and hospital care for two weeks while the woman remained for treatment.
The next step is to perform an analysis, beginning with an impacted goal and asking ‘why’ questions. In this case, the details that have been released show that the epidural was given with a cleaning fluid when the usual drug was confused with the chlorhexidine and administered when the patient requested an epidural. The bottles of the two drugs were apparently switched, though at what point is unclear. Obviously the check of the drugs was ineffective as the result was the wrong drug being administered to a patient.
More detail can be added to the Cause Map as it is discovered during an investigation. The hospital involved is addressing the cause of the cleaning fluid being present in the same area as the medication by removing the cleaning chemical. Said Anders Rehn, acting director of the hospital, “We consider this extremely serious. Obviously this shouldn’t happen. We have removed the containers so they cannot be switched. The chemical is no longer in the birthing clinic.”
Though this will strongly reduce the risk of this particular chemical being mistaken for a medication, the medication administration process should still be examined for improvement to reduce the risk of other medication errors.
Other chemical mix-ups have been in the news recently. A restaurant mixed an odorless cleaning-compound lye used for de-greasing the deep fryer into iced tea after mistaking it for sugar. The only woman who drank the tea received burns in her esophagus but is making a ‘miraculous’ recovery. Long-term effects will be determined by ongoing tests and procedures. It was also determined that an employee was burned by the chemical which had been placed in a sugar container.
Two weeks later, a boy drinking a milkshake complained it didn’t taste right. The milkshake had been contaminated with cleaning product after a worker picked the cleaning product container out of the sink, thinking it had been washed, and filled it with vanilla syrup. At least two other customers apparently drank the milkshake and were treated at hospital. Clearly it’s not only medical facilities that need to ensure that there is a high level of protection between items meant for human internal use. Lessons learned from this incident can be applied to all types of industries to ensure customer safety.