Near Miss Analysis: The Case of Jany
The Case
Jany, a 77-year-old woman on anticoagulation for her recent and historic deep venous thrombosis showed symptoms of dizziness at the emergency department (ED). In the ED, she presented heart rate of 44 beats in a minute, this was believed to be the cause of her symptoms. Upon digging into her medical history, the patient revealed a recent increase of her beta-blocker. The blood pressure medication is administered to reduce heart rates.
At the ED, the Registered Nurse (RN) was worried with the weakening heart rate. She placed an ordered for syringe of atropine to be set at the patient’s bedside. Atropine is a known strong anti-cholinergic medication. It is only administered in emergency situations to boost slowed heart rates. Improper administration of the drug can cause severe heart rate and at times result to convulsion or unconsciousness among patients. As a result, it is only administered under keen physician observation.
Fortunately, Jany’s heart rate started to show improvement while still at the ED. The nurses planned to discharge her with instruction to slow that she slows down the beta-blocker dose. Notably, Jany’s anticoagulation; her international normalized ratio [INR]) on oral blood thinner was determined to be low. The instruction indicated that alongside decreasing his beta-blocker dose, she needed low-molecular-weight heparin (LMWH) injection while at home to ensure anticoagulation to boost INR rise to the normal range.
The pharmacist was invited at the ED to instruct Jany on subcutaneous LMWH injections, the injection was required twice a day. However, Jane showed signs that she was not comfortable with the medication process, but the pharmacist believed she was ready for discharge with the instructions. The pharmacist surrendered to the patient 10 pre-filled syringes the desired LMWH does. The dose would take her to the next anticoagulation clinic visit.
During the discharge, Jane packed everything, but carried with her the LMWH box, and that of atropine syringe that laid next to her bedside. Jany, went home with two medicines! While at home, she attempted injection the atropine, but unluckily, the all over her body. Point to note, he atropine syringe does not come with a needle, the injection is usually direct into IV peripheral. In the confusion, Jany dialed the pharmacist. The pharmacist had him spell the name on the box, and was astounded. She asked Jany to discard the atropine box and all its content. It was fortunate that Jany did not inject the atropine. This is among the many near miss that happens every day in the care centers.