IHP 315 Module 4 Project One Example

Project One: Analysis of a Weight-Entry Heparin Dosing Error

[Student Name]

Southern New Hampshire University

IHP 315: Patient Safety Systems and Strategies

Project One

[Instructor Name]

[Date]

Project One: Analysis of a Weight-Entry Heparin Dosing Error

Heparin is a high-alert medication: when it is dosed wrongly, patients can bleed or clot with serious consequences. This project analyzes an event at Maple Grove, a composite community hospital, in which a heparin infusion started at nearly double the intended dose. The patient recovered, but the event exposed weaknesses at almost every step between admission and the infusion pump. The analysis reconstructs what happened, identifies contributing factors using a work system model, explains how the defenses failed and recommends actions ranked by their likely effectiveness. Names and details are changed.

What Happened

A 72-year-old woman arrived in the emergency department on a busy Saturday evening with a blood clot in her leg. She could not stand on the department's scale, so the triage nurse asked her weight, and she said 176. The nurse typed 176 into the weight field, which accepted either pounds or kilograms depending on a drop-down menu that defaulted to kilograms. The physician ordered a weight-based heparin protocol, and the electronic record calculated a bolus and infusion rate for a 176-kilogram patient, about 80 kilograms more than her real weight of roughly 80 kilograms.

The pharmacist on duty, covering the emergency department and three inpatient units, verified the order. The dose was within the protocol's calculated range for the recorded weight, so no alert fired. On the medical unit, two nurses completed the required independent double check, comparing the pump settings with the order, which matched. The pump was run in basic mode rather than with its drug library because the library entry for heparin had been updated and nurses were unsure of the new profile. Six hours later, the patient's clotting test came back far above target, and she had blood in her urine. The infusion was stopped, the error discovered and the patient monitored. She recovered without lasting harm.

Contributing Factors: A Work System View

The SEIPS model of Carayon et al. (2006) was built to help health care organizations see how the parts of a work system, the people, the tasks, the tools and technology, the physical environment and the organization, interact to shape care processes and outcomes. Applied to this event, the model shows that no single factor caused the harm. The patient could not use the standing scale, and no bed or chair scale was available. The triage task required a weight quickly, under pressure. The electronic record allowed either unit, defaulted to kilograms and had no warning for an implausible weight. The pharmacist's dose check relied on the recorded weight, so a wrong weight produced a correct-looking dose. Nurses checked the pump against the order but never checked the order against the patient. The pump's safety library was bypassed. And the organization had staffed one pharmacist for four areas on a weekend evening.

Table 1. Contributing Factors by Work System Element

Note. Factors are drawn from interviews and record review.

How the Defenses Failed

Reason (2000) described safety defenses as layers, each with weaknesses, and argued that harm occurs when those weaknesses line up. He contrasted the slips people make at the point of care with deeper flaws planted by earlier design and management choices, flaws that can lie dormant until an active failure exposes them. In this event, the active failure was entering 176 without switching the unit. Every other layer, the dose check, pharmacist verification, double check and smart pump, should have caught it, and each failed because of a latent condition: a check that trusted the weight, a double check aimed at the wrong comparison and a safety library that staff avoided. Blaming the triage nurse would leave all of those conditions in place for the next patient.

Avoiding Weak Fixes

Wu et al. (2008) reviewed how root cause analysis is used in medicine and found little evidence that it reliably prevents recurrence. They noted that analyses often end with weak actions, such as reminders, education and new policies, that depend on people remembering to do better, and that recommendations frequently go unimplemented. They urged organizations to favor stronger actions that change systems and to track whether actions are completed and effective. This analysis therefore ranks recommendations by strength, preferring forcing functions and standardization over training.

Recommendations Ranked by Strength

Top-ranked actions make the slip nearly impossible to repeat. The record should accept weights only in kilograms throughout the hospital, with a hard stop requiring confirmation for adult weights above 150 kilograms or below 35. The smart pump drug library should be mandatory for heparin, with the basic mode locked for high-alert drugs. Moderate actions standardize and simplify: bed and chair scales should be placed in the emergency department so weights are measured rather than stated, and the double-check form should require comparing the order's weight with the patient's measured weight. Weaker but still useful actions include a pharmacist workload review for weekend evenings and brief education on the updated heparin library.

Each action has an owner. Informatics owns the weight field change within sixty days, pharmacy owns the pump library lock within thirty, the emergency department manager owns scale purchase and nursing education owns the revised double-check form.

Table 2. Actions, Strength and Owners

Note. Strength reflects how little each action depends on memory or vigilance.

Measuring Whether Actions Work

The patient safety office will track completion of each action by its deadline. Afterward, informatics will report monthly how often the weight hard stop fires and how often weights are corrected, pharmacy will report the share of heparin infusions run through the drug library, targeting 100%, and the emergency department will audit twenty records a month for measured versus stated weights. Any heparin dosing error will receive rapid review to see whether it slipped past the new defenses.

Conclusion

A single typing slip passed through four defenses because each was built with a hidden weakness. Retelling the event as a system story shows that the fixes belong to informatics, pharmacy, equipment and policy, not to one nurse, and ranking actions by strength gives the hospital a better chance of preventing the next event.

References

Carayon, P., Schoofs Hundt, A., Karsh, B.-T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 15(Suppl. 1), i50-i58. https://doi.org/10.1136/qshc.2005.015842

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768

Wu, A. W., Lipshutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. JAMA, 299(6), 685-687. https://doi.org/10.1001/jama.299.6.685