I’ve Been Thinking about the Dodgers, George Carlin, Nurse Jackie and drugs—oh yeah, and near misses

I’ve been thinking about the Dodgers, George Carlin, Nurse Jackie and drugs—oh yeah, and near misses.

It’s Monday about to turn Tuesday. Our return flight to Seattle has been weather-delayed after our weekend in So Cal. On Saturday, we nearly missed the Yankees/Dodgers game due to an equipment-delay. United’s mechanics came close to cancelling our southbound journey. Not sure why. It was only the navigational system.

In April, near Dodger Stadium at Bob Hope International, two planes were involved in what The Huffington Post called a “near miss.” A jetliner came within two plane lengths of colliding with a Cessna. Was the collision-avoidance interface to the plane’s navigational system on the blink? It’s all under investigation. Meanwhile, I’m thinking about George Carlin’s airline routine. “Here’s one they just made up. When two planes almost collide, they call it a near miss. It’s a near hit! A collision is a near miss. Boom. Look, they nearly missed.”

Then Carlin’s routine comes in for a landing. “Which brings me to terminal—another unfortunate word to be used in association with air travel.” Had he known how many medication errors kill patients, he might have applied terminal to hospitals.

Last year ISMP surveyed Medication Safety Alert readers regarding the definition of a near miss. Eighty-eight percent of the 3,800-plus respondents defined a near miss as “an error that happened but did not reach the patient.” However, a significant number also felt near miss is a misnomer—enough for ISMP to revise their nomenclature. One respondent argued, “A near miss is more applicable when trying to hit something, not avoid something.” Another reader suggested “close call” is a better term. ISMP agreed: “Although near miss appears to be well entrenched in healthcare terminology, we will try to refer to near misses as close calls when feasible in the future to prevent confusion.”

The recent study out of Boston provides evidence that bar-code verification technology coupled with electronic medication-administration systems (bar-code eMAR) “substantially reduced” medication errors at the point of care. The May 6, 2010, New England Journal of Medicine reported that the Brigham and Women’s Hospital realized a 51 percent relative reduction in adverse drug events with bar-code eMAR. “Because the study hospital administers approximately 5.9 million doses of medications per year, use of the bar-code eMAR is expected to prevent approximately 95,000 potential adverse drug events at the point of medication administration every year in this hospital.”

How about these near hits (close calls) I’ve recently learned about from pharmacy friends across the country? Credit bar-code eMAR for the saves.

• A nurse intending to administer IV vancomycin grabs an epidural bag by mistake. Scanning brings up a “wrong drug” alert and intercepts the error.
• Scanning triggers a “wrong patient” alert, stopping another nurse from administering penicillin to a patient who is severely allergic to the drug.
• Bar-code scanning saves an infant’s life by intercepting a 10-fold overdose of hydromorphone.

Besides preventing catastrophes, bar-code eMAR systems gather close-call data, which is useful for identifying gaps and improving the medication-use process. The idea is to eliminate errors upstream, preventing them from trickling down to points of care.

Over four months at one hospital, bar code eMAR interrupted nurses on three different occasions from administering Amiodarone when Mannitol had been ordered. Had the Amiodarone been administered at the prescribed Mannitol rate, the errors could have been fatal. Reviewing close-call reports led pharmacy to revisit their dispensing processes. In each instance, they discovered nurses had grabbed glass bottles from the pharmacy drop box without reading the labels. To decrease the opportunity for error, pharmacy switched Mannitrol to PVC bags so they would not be so easily confused with Amiodarone glass bottles on the units.

In the finale of Nurse Jackie’s inaugural season on Showtime, ER nurse Jackie orders Zoey to give 50 mcgs of Fentanyl to Mr. Netterman. The young nurse mistakenly administers 250 mcgs—putting their patient in a coma.

ER nurse manager Gloria wastes no time launching an investigation. While boarding an elevator she barks at Jackie, “I want to see you and Zoey in my office in five minutes.” After the doors close the elevator miraculously malfunctions. Whereupon extremely ex-Catholic Jackie relapses and whispers, “Thank you, Jesus.” Who wouldn’t be grateful to dodge a come-to-Jesus meeting?

I regularly hear about bedside epiphanies in which scanning protects nurses from harming their patients—a much better place for a thank-you-Jesus experience, if you ask me.

Well, its 2:30 AM and we’ve just landed in Seattle. Nevertheless, our flight—thank you Jesus—did not include a near miss or any close calls, for that matter. Unfortunately, the Dodgers didn’t fare as well. They had a near win because Yankee Robinson Cano nearly missed a home run in the tenth. I’d bet you a Dodger Dog those damn Yankees are thanking the baseball gods that a miss is as good as a mile as they’re winging their way to New York. The boys from the Bronx are headed for a three-game series with my Mariners.

What do you think?

Mark Neuenschwander a.k.a. Noosh

P.S. Have you seen the trailer for 30 Rock, in which NBC executive Jack Donaghy (Alec Baldwin) announces to a uniformed airline captain (Matt Damon), “I’m developing a talk show with Sulley Sullenberger.”

“Eh,” says the pilot, “he’s not that great. You know what a great pilot would have done? Not hit the birds. That’s what I do every day, not hit birds. Where’s my ticket to the Grammys?”

Is it just me or is there a lesson in there somewhere?

Late-breaking news: My Mariners (thank you Jesus) had a near sweep, taking 2 of 3 from Yankees.