KNOWLEDGE-BASED ERROR

What happened?

Bruce Lee’s death after meeting with Lazenby, Lee decided to visit the apartment of his
mistress, Betty Ting Pei, for a “nooner.” Around 6 p.m., Raymond Chow, Lee’s business
partner, arrived. The three of them were scheduled to meet Lazenby for a celebratory
dinner, but before they left, Lee complained of a headache. Betty gave him one of her
prescription pain medications, which contained aspirin. Lee told Chow to go on without
them. He went to lie down on Betty’s bed—and never got back up again. With the
investigation at a standstill, the government flew in an expert from London who offered a
novel hypothesis: severe allergic reaction to aspirin, or anaphylactic shock. The official
cause of Lee's death was listed as cerebral edema, a swelling of the brain, and attributed
to an allergic reaction to a painkiller called Equagesic.

• A famous man in Hong Kong named Bruce Lee went to Betty's apartment, his
mistress then around 6 pm, Raymond Chow, his business partner arrived.
• The three of them scheduled a celebratory dinner but before they left, Lee
complained of a headache.
• Betty gave him one of her prescription pain medications, which contained aspirin.
Lee told Chow to go on without them.
• He went to lie down on Betty's bed—and never got back up again.
• With the investigation at a standstill, the government flew in an expert from London
who offered a novel hypothesis: severe allergic reaction to aspirin, or anaphylactic
shock.
• The official cause of Lee's death was listed as cerebral edema, a swelling of the
brain, and attributed to an allergic reaction to a painkiller called Equagesic.

Solutions

• Identify a drug allergy.

• Monitor drugs with narrow therapeutic indexes
 • If unsure about the drug or the dose, speak to the pharmacist.
• Always consider the fact that each medication has the potential for adverse
reactions. Always be aware of high-risk medications.
• When writing a prescription, state the condition being treated

https://www.history.com/news/bruce-lee-death-mystery-solved-sweat-glands

RULE-BASED ERROR

What Happened?

In late 2017, Vaught, a nurse, mistakenly administered the wrong medication to patient
Charlene Murphey while Murphey awaited a radiologic study at Vanderbilt University
Medical Center. Murphey died as a consequence of the error, and an investigation later
found that multiple patient safeguards that should have existed in the hospital had been
absent or failing at the time of the event and were partially responsible for her death.
Vaught’s errors included removing the wrong medication from one of the hospital’s
electronic prescribing cabinets, overlooking several warnings on the medication vial, and
not monitoring Murphey’s vital signs after administering the medication.

• In late 2017, Vaught, a nurse, mistakenly administered the wrong medication to

patient Charlene Murphey while Murphey awaited a radiologic study at Vanderbilt
University Medical Center.
• Murphey died as a consequence of the error, and an investigation later found that
multiple patient safeguards that should have existed in the hospital had been
absent or failing at the time of the event and were partially responsible for her
death.
• Vaught's errors included removing the wrong medication from one of the hospital's
electronic prescribing cabinets, overlooking several warnings on the medication
vial, and not monitoring Murphey's vital signs after administering the medication.

Solutions

• Prior to administration, review the medication and dosing.

 • Do not overlook the warnings on medications.

https://www.vox.com/science-and-health/2022/5/13/23066994/radonda-vaught-
sentence-medication-error-patient-safety-lawsuit-vanderbilt-probation

ACTION-BASED ERROR

What happened?

There is a total of 68 errors that were discovered in the Eric Williams Medical Sciences
Complex's adult outpatient pharmacy. The majority of the error's source is in the pediatric
outpatient pharmacy and the inpatient pharmacy. Excessive workloads for pharmacists,
brands and medications with similar phonetic names, delays and distractions during the
dispensing process are some variables that might cause dispensing errors. Patients may
experience unnecessary pain and discomfort due to dispensing errors of the pharmacists.

• There is a total of 68 errors that were discovered in the Eric Williams Medical
Sciences Complex's adult outpatient pharmacy.
• The majority of the error's source is in the pediatric outpatient pharmacy and the
inpatient pharmacy.
• Excessive workloads for pharmacists, brands and medications with similar
phonetic names, delays and distractions during the dispensing process are some
variables that might cause dispensing errors.
• Patients may experience unnecessary pain and discomfort due to dispensing
errors of the pharmacists.

Solutions

• Organize the workplace

• Be familiar with the medicines
• Avoid distraction when possible
• Beware of sound alike drugs

https://joppp.biomedcentral.com/articles/10.1186/s40545-020-00263-x
MEMORY-BASED ERROR

What happened?

Good Samaritan Medical Center in Brockton, Massachusetts had an incident last

December 2018. A nurse ordered and a pharmacist approved a pain reliever for a patient
whose EHR (Electronic Health Record) indicated a life-threatening allergy to the drug.
The nurse and pharmacist did not notice a warning box that alerted them on their
computers. The nurse administered the nonsteroidal anti-inflammatory drug to the patient.
The patient suffered a severe and life-threatening reaction to the drug and had to be
transferred to the intensive care unit and sooner recovered from it.

• Good Samaritan Medical Center in Brockton, Massachusetts had an incident last

December 2018.
• A nurse ordered and a pharmacist approved a pain reliever for a patient whose
EHR (Electronic Health Record) indicated a life-threatening allergy to the drug.
• The nurse and pharmacist did not notice a warning box that alerted them on their
computers.
• The nurse administered the nonsteroidal anti-inflammatory drug to the patient.
• The patient suffered a severe and life-threatening reaction to the drug and had to
be transferred to the intensive care unit and sooner recovered from it.

Solutions

• Properly implementing barcode medication administration systems, which require

the clinician to scan a barcode on a patient’s wristband before giving medicine.
That process checks with an EHR for patient allergies and potentially harmful drug
interactions.
• Do cross-checking before administering medications.

https://www.healthcaredive.com/news/alert-fatigue-a-focus-after-patients-drug-allergy-
warning-missed/525271/