September 30, 2009 | Mark Paradies

Three Human Safeguards Fail – Boy Dies Due to Painkiller Overdoes

failed safeguard

He went in for a “routine” dental cleaning and tooth extraction at a hospital in Seattle.

Things went OK. They gave him a prescription for a painkiller.

The doctor (a DDS resident) prescribed it.

The nurse checked it.

The pharmacist checked it.

The prescription was slightly unusual – a fentanyl transdermal patch. The doctor decided to use this pain reliever because the boy was autistic and could not tolerate liquid or pill-form medication.

What all three people failed to notice was that this form of medication was highly potent and was only used by people who had already built up a tolerance to opioids. Otherwise, these drugs can kill by stopping respiration.

But the doctor, the nurse, and the pharmacist missed this.

Now it gets interesting.

The doctor performing the surgery didn’t prescribe the medicine. Instead, a resident that was assisting wrote the prescription. It isn’t clear if the doctor performing the surgery reviewed the prescription or not.

Some questions that weren’t answered by the article:

– How many hours had the resident worked? (Was fatigue an issue?)

– How did the resident pick that drug?

– How did the packaging and prescription tools warn about the care needed in prescribing and using this drug?

The hospital’s corrective action was to add more human action safeguards around the prescription of this drug (additional reviews).

What do you think? Is this sufficient?

Root Cause Analysis
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