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Lack of a no-blame culture and a complex medical system that is vulnerable to errors contributed to the deaths of two patients at a Canadian hospital, according to an independent investigation.

Patient Safety Monitor Alert, July 12, 2004

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Lack of a no-blame culture and a complex medical system that is vulnerable to errors contributed to the deaths of two patients at a Canadian hospital, according to an independent investigation.

The probe resulted in an 83-page report that was released June 29. The report urges the Calgary Health Region (CHR) to redouble its efforts to build a culture of patient safety, including by developing "a clear policy describing the way in which staff involved in healthcare system failures will be treated by management."

"Such a policy is essential to the development of a solid patient safety culture in the region and will create the necessary conditions for a robust and effective critical incident reporting system," the report states.

Two critically ill patients died at Foothills Medical Centre in Calgary in February and March after they received potassium chloride instead of sodium chloride for their continuous dialysis. CHR's central pharmacy had mixed the solution.

Sodium chloride, better known as salt, helps to regulate the safe fluid levels in the body. Potassium chloride is used for a range of applications, including medicine and food. It's also infamous as the lethal injection for death row inmates, since high doses can cause cardiac arrest.

In the aftermath, CHR asked Rob Robson, MD, director of patient safety for the Winnipeg Regional Health Authority, to review CHR's practices, including how medications are prepared and distributed at its central pharmacy.

Robson found no evidence of carelessness, incompetence, or willful violation of policies. However, he did unearth dozens of systemic shortcomings that render CHR vulnerable to human error.

Robson described the importance of establishing a blame-free reporting culture as a "central issue" to preventing errors.

"The ultimate goal is to uncover real and potential problems at an earlier stage," he wrote, "so that appropriate lessons can be learned and corrective actions taken." His report, released in late June, outlines 66 recommendations for better patient safety. The CHR has said it hopes to begin implementing the recommendations by this fall.

Many of the recommendations are already in place in U.S. hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations.

The report's suggestions include:

• use bar code technology wherever possible to verify the accuracy of product selection and administration
  
• examine the feasibility of using commercially prepared dialysate solutions
  
• isolate high-risk medications in all pharmacy work areas
  
• develop a comprehensive strategy for handling and administering high-risk medications
  
• think twice about look-alike packaging when making purchasing decisions. Use alternate suppliers if possible
  
• perform a final check of the ingredients before administering a prepared dialysate solution

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