Error Prevention and Patient Safety

After watching the video, “Chasing Zero”, I chose to summarize the story of the twin babies who received overdose of Heparin. The twins are supposed to receive HepLock 10 units, but nurse of Cedars-Sinai administered Heparin 10,000 units. Further investigation was done and they found out that the 10-unit pediatric dose and the 10,000-unit adult dose come in vials of identical shape and in different shades of blue that can be easily confused, if not seen in reference to each other. After the incident, Baxter, the company who manufactures the medication issued a nationwide safety alert and they started shipping Heparin with a redesigned, peel-off label to end the confusion. Cedars-Sinai Hospital acknowledged serious mistakes and did not dispute the findings. Investigation found critical systems failure in which pharmacy technicians and nurses neglected to check the drugs they were distributing and administering. System failures include: failure to carefully and accurately read the label on the medication vial prior to administering the drug to the patient, inaccurate filling of automated drug-dispensing cabinets, non-distinct “look-alike” labels on the heparin vials, similar size of the heparin vials as both were 1-mL vials, and “factor of ten” dosing errors. (Arimura, Poole, Jeng, Rhine, Sharek, 2008)

Medication errors are widespread in the healthcare system. An advanced practice nurse plays an important role in preventing errors by taking leadership roles within the practice setting to promote quality and safety for the patients. Using bar-coded medications, electronic medical records, rewriting medication directions (so they are easier to understand), higher health literacy, and closer monitoring of at-risk groups such as infants and the elderly can prevent medication error. (Denisco & Barker, 2016, p. 304) An APN can contribute to a culture of patient safety by promoting a process designed to prevent errors. APN must recognize safety as a top priority; expectations and actions promoting patient safety are regularly communicated to the healthcare team. Additionally, encouraging open communication so that everyone feels free to report potential safety concerns, non-punitive response to error, teamwork within units and across hospital units will help in fostering a culture of safety.

Based from Alkhenizan and Shaw (2011), general accreditation programs appear to improve the structure and process of care with a good body of evidence showing that accreditation programs improve clinical outcomes. Several studies showed that general accreditation programs significantly improve clinical outcomes and the quality of care of these clinical conditions and showed a significant positive impact of subspecialty accreditation programs in improving clinical outcomes in different subspecialties. In the United States, The Joint Commission and Centers for Medicare and Medicaid Services are committed in improving healthcare safety for the public by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.


Arimura, J., Poole, R. L., Jeng, M., Rhine, W., & Sharek, P. (2008). Neonatal Heparin Overdose—A Multidisciplinary Team Approach to Medication Error Prevention. The Journal of Pediatric Pharmacology and Therapeutics: JPPT,13(2), 96–98.

Denisco, S. M., & Barker, A. M. (2015). Advanced practice nursing. Burlington, MA: Jones & Bartlett Learning.

Alkhenizan, A., & Shaw, C. (2011). Impact of Accreditation on the Quality of Healthcare Services: a Systematic Review of the Literature. Annals of Saudi Medicine31(4), 407–416.