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Journal Article > Commentary
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
This article discusses how a hospital responded to a fatal medication error that occurred when a nurse mistakenly administered epidural pain medication intravenously to a pregnant teenager. Findings from the root cause analysis of the error revealed underlying factors including fatigue (the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented a bar coding system, but not all nurses were trained and workarounds were routine), and human factors engineering (bags containing antibiotics and pain medications were similar in appearance and could be accessed with the same type of catheter). A range of safety interventions were implemented as a result. However, the related editorials by leaders in the safety field (Drs. Sidney Dekker, Charles Denham, and Lucian Leape) take the hospital to task for focusing on narrow improvements rather than using complexity theory to solve underlying problems, and for creating a "second victim" by disciplining the nurse (who was fired and ultimately criminally prosecuted) rather than acknowledging the institution's responsibility and the caregiver's emotional distress. The article and commentaries provide a fascinating, in-depth look at the true impact of a never event.
Journal Article > Study
Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors.
Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Jt Comm J Qual Patient Saf. 2019;45:249–258.
An unintentionally retained foreign object during a surgery or a procedure is considered a never event and can result in significant patient harm. Researchers retrospectively reviewed 308 events involving unintentionally retained foreign objects that were reported to The Joint Commission to better characterize these events, determine the impact on the patient, identify contributing factors, and make recommendations for improving safety.