• Cases & Commentaries
  • Published November 2003

40 of K

The Case

An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit nurse contacted the physician, who was engaged in a sterile procedure in the cardiac catheterization laboratory (cath lab) and gave a verbal order, which was relayed to the unit nurse via the procedure area nurse. Someone in the verbal order process said "40 of K." The unit nurse (whose past clinical experience was in neonatal intensive care) wrote the order as "Give 40 mg Vit K IV now."

The hospital pharmacist contacted the physician concerning the high dose and the route and discovered that the intended order was "40 mEq of KCl po." The pharmacist wrote the clarification order. However, the unit nurse had already obtained vitamin K on override from the Pyxis MedStation® (an automated medication dispensing system) and administered the dose intravenously (IV). The nurse attempted to contact the physician but was told he was busy with procedures. A routine order to increase warfarin from 2.5 mg to 5 mg (based on an earlier INR) was written later in the day and interpreted by the evening shift nurse as the physician's response to the medication event. The physician was not actually informed that the vitamin K had been administered until the next day. Heparin was initiated and warfarin was re-titrated to a therapeutic level. The patient's INR was subtherapeutic for 3 days, but no untoward clinical consequences occurred.

The Commentary

This case illustrates how seemingly low-risk patient care activities create the opportunity for serious errors to occur. The initiating event in this case was a breakdown in communication during the ordering of a medication ("40 of K").

Telephone and Verbal Orders

The use of verbal or telephone orders is cited as an error-prone process by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (1), the Institute for Safe Medication Practices (ISMP) (2), and the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP).(3) A key 2003 JCAHO Patient Safety Goal (1) is to minimize the use of verbal or telephone orders, but if used, the order should be immediately transcribed and read back for confirmation. The common perception of increased risk has prompted many hospitals to implement policies restricting such orders to urgent medical situations. The data on errors with verbal orders, however, is mixed. One recent study found an increased risk of hospital prescribing errors when orders were verbally transmitted or were transcribed by nurses.(4) However, the only systematic evaluation of error risk by mode of transmission found that verbal and telephone orders carried a similar or lower error risk than written orders. Verbal orders did have increasing error rates as the order complexity increased, something not seen with written orders.(5)

Sending Messages Through a Third Person and "Multitasking"

Another possible contributing factor here was the transmission of the order via a third person (the procedure area nurse). Moreover, the physician gave the order while performing a procedure in the cath lab. Communicating through a third person while "multitasking" not only increases the risk of miscommunication, but also reduces the effectiveness of the confirmation process and lessens the likelihood that effective communication occurs if questions arise about the order.


Abbreviation use contributed to the miscommunication in this case. The abbreviation "K" led to administration of the wrong drug. Such short cuts place patients at unnecessary risk for error. The contribution of abbreviations to medication error is well documented, and several organizations recommend that abbreviation use therefore be restricted or limited.(1,6-8) JCAHO now requires that health care organizations establish a list of prohibited abbreviations (1) and that such organizations implement policies to reduce risk from resultant communication errors. Abbreviation of dose units, dosage form, dose routes, dose rates, and frequency will similarly produce errors in drug orders, and should be avoided.

Knowledge, Culture, and Communication

An additional, and equally important, consideration in this case is the nurse's failure to attempt to verify the appropriateness of an order that she considered questionable. The transcribed order for "40 mg vitamin K IV now" was rationalized as appropriate rather than confirmed with the prescriber. The underlying reasons for this are multiple. Caregiver knowledge and access to patient and drug information is often inadequate to accurately and efficiently evaluate medication orders for appropriateness.(9) When an order is not clearly wrong, many caregivers will rationalize a questionable order by deferring to the knowledge of the prescriber. Cultural and interpersonal factors also play a role. Hesitancy to challenge or question prescribers may be a cultural norm within the organization. Difficult or intimidating prescribers create hesitancy among providers to discuss potential issues. Even creating the perception that the prescriber is "busy" will reduce the likelihood that caregivers will question an order they are not certain is in error. As a result, questionable orders may be honored without contacting prescribers for verification.

Particularly telling in this case is the fact that the physician was not promptly informed of the error. The fear of openly communicating the error could have resulted in significant patient harm. When errors are not immediately communicated, the risk to patients is greatly increased, and the opportunity to ameliorate potential harmful effects is missed. High reliability organizations such as the airline industry and military have striven to decrease risk of accidents by reducing "authority gradients" and promoting effective teamwork and communication. Caregivers likewise must view the fostering of open and effective communication to be an essential patient safety function. Behaviors that inhibit communication place patients at greater risk for an adverse drug event (ADE). Caregivers should be coached in techniques for communicating and resolving conflicts.(10) The ADE described here might have been avoided if the nurse had improved decision support for order evaluation or if the culture had strongly supported questioning any order in doubt.

No Pharmacist Order Review and Uncontrolled Automatic Dispensing Cabinet Medications

Pharmacist review of medication orders is a key safety procedure whose benefits have been demonstrated.(11) Except in medically urgent situations in which a delay presents possible patient harm, JCAHO standards (12) require that pharmacists review medication orders prior to administration. When not performed (ie, due to emergency), order review should occur as quickly as possible. In this case, the pharmacist review detected the error, but it was too late.

While rapid provision of drug therapy is sometimes critical, the important safety step of pharmacist review is often bypassed unnecessarily for sake of "efficiency." Automatic dispensing devices (ADDs) (Figure 1, Figure 2), in which medications may be accessible to caregivers prior to pharmacist review, are used in almost 60% of hospitals (13) as a method of drug distribution. Despite widespread use of ADDs, information regarding their impact on patient safety is limited. Available studies demonstrate that ADDs might reduce "wrong time" (usually late) medication errors, but possibly increase risk for more serious wrong drug and wrong dose errors.(14) The ISMP Medication Safety Alert! (available at: http://www.ismp.org/MSAarticles/msa.html) has reported serious and fatal medication errors resulting from uncontrolled access to medication from ADDs. The uncontrolled access is provided by either failing to have the device interfaced with the pharmacy computer (the interface allows only pharmacy-approved medications be available), or by using an "override" process, which is meant to provide a method for caregivers to gain access to medications quickly in an emergency. JCAHO standards require that overrides be carefully controlled and limited to urgent situations. In 2002, however, US hospitals reported that 22.8% of all doses dispensed from ADDs were obtained using overrides.(13) Clearly this number far exceeds what one would expect if the process were used only for medically urgent situations. One 550-bed hospital reported that more than 75 overrides occurred each day for antibiotics alone. Review of these overrides demonstrated an error rate of 21%, mainly due to obtaining antibiotics after the drug was discontinued.(15)

To reduce risk to patients, organizations must carefully evaluate and control which medications are provided in ADDs prior to pharmacist review. Factors to consider include the care setting, patient types, risk for error, drug product characteristics, type of ADD, and ability of pharmacy to supply the medication in a timely fashion. Whenever medications are accessible from ADDs or other uncontrolled medication supplies, clear policies and procedures should exist regarding when medications can be accessed. Appropriate safety procedures such as warnings, limiting medication amounts, special labeling and packaging, second person double checks, staff education, and process oversight must be in place. When medications must be obtained from an ADD and administered prior to pharmacist review, the order should be sent to the pharmacy for review as soon as possible.

Take-Home Points

  • All medication orders create an opportunity for error. Whenever feasible, defer all necessary prescribing until the safest possible conditions exist.
  • Limit the use of telephone and verbal orders. Always request a "read-back" of the transcribed order.
  • Communication between caregivers is critical for patient safety. Prescribers should actively encourage communication and welcome the questioning of their orders.
  • Pharmacist review of medication orders reduces risk of error and should not be circumvented for convenience.
  • Automated dispensing devices have not been shown to improve patient safety, and may increase patient risk if not wisely implemented. Accessing medications from ADDs prior to pharmacist order review and release circumvents the traditional safety constraints of medication control.

Timothy S. Lesar, PharmD
Director of Pharmacy
Albany Medical Center


1. 2003 JCAHO National Patient Safety Goals: practical strategies and helpful solutions for meeting these goals. Joint Commission Perspectives on Patient Safety. 2003;3:1-11.
[ go to related site ]

2. Smetzer J, Cohen MR. Instilling a measure of safety into those "whispering down the lane" verbal orders. ISMP Medication Safety Alert! 2001;6:1-2.
[ go to related site ]

3. National Coordinating Council for Medication Error Reporting and Prevention. Recommendations to reduce medication errors associated with verbal medication orders and prescriptions. February 20, 2001.
[ go to related site ]

4. Fijn R, Van den Bemt PM, Chow M, De Blaey CJ, De Jong-Van den Berg LT, Brouwers JR. Hospital prescribing errors: epidemiological assessment of predictors. Br J Clin Pharmacol. 2002;53:326-31.
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5. West DW, Levine S, Magram G, MacCorkle H, Thomas P, Upp K. Pediatric medication order error rates related to the mode of order transmission. Arch Pediatr Adolesc Med. 1994;148:1322-6.
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6. Smetzer J, Cohen MR. U cnt abbrv "patient safety." ISMP Medication Safety Alert! 2003;8:1.
[ go to related site ]

7. Institute for Safe Medication Practices. Do not use these dangerous abbreviations or dose designations.
[ go to related site ]

8. National Coordinating Council for Medication Error Reporting and Prevention. Recommendations to correct error-prone aspects of prescription writing. September 4, 1996.
[ go to related site ]

9. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.
[ go to pubmed ]

10. Smetzer J, Cohen MR. Face it! Intimidation presents serious safety issues. ISMP Medication Safety Alert! 2002;7:1-2.
[ go to related site ]

11. Lesar TS, Lomaestro B, Pohl H. Medication-prescribing errors in a teaching hospital: a 9-year experience. Arch Intern Med. 1997;157:1569-76.
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12. Rich DS. More on automated dispensing machines. Hosp Pharm. 2001;36:220-223.

13. Pederson CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration-2002. Am J Health-Syst Pharm. 2003;60:52-68.
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14. Murray MD. Automated medication dispensing devices. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making health care safer: a critical analysis of patient safety practices. Rockville, MD: Agency for Healthcare Research and Quality; 2001: 111-116. AHRQ publication 01-E058. Evidence report/technology assessment. no. 43.
[ go to related site ]

15. Oren E, Griffiths LP, Guglielmo BJ. Characteristics of antimicrobial overrides associated with automated dispensing machines. Am J Health Syst Pharm. 2002;59:1445-8.
[ go to pubmed ]


Figure 1. Automated Dispensing Device With Individually Locked Cubicles to Control Access to Medications.

Photograph of an automated dispensing device.

Figure 2. Automated Dispensing Device With "Open" Matrix Drawer That Allows Uncontrolled Access to Multiple Medications.

Photograph of an automated dispensing device.
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