In May 2014, four-year-old Logan Wells almost died in hospital when he was given a concentration of potassium chloride that was five times too high.

 

A lot of things went wrong the day Logan almost died in hospital.

“It was a perfect storm,” says Linda Asztalos, the registered nurse who hung Logan’s IV. “I’ve been a nurse for 24 years, and an error like this is devastating. I have three kids myself and can’t imagine being on the other end.”

“Multiple mistakes were made throughout the morning,” she continues, explaining that neither the pre-operation checklist nor the safety check had been completed, the prescription order was not double checked before the potassium was given, and the porters arrived early to take Logan (who was dehydrated and vomiting) to the operating room.

Even so, Allison Wells, Logan’s mother, says she firmly believes everyone that day was working with her son’s best intentions in mind.

“I work in the system myself, and I’ve seen errors, I’ve been involved in errors before, but the way Saskatoon Health Region handled this error has been incredible,” says Allison. “Their openness to understand that there are safety defects in the system, and their openness to work with me and to try and fix them, has been unlike anything I’ve experienced in my own healthcare career to this point.”

Immediately following the medication error, Jackie Mann, vice president of Integrated Health Services, went to the pediatrics unit to see how potassium chloride was being delivered.

“It became clear that in the situation Logan was in, there was room for mistakes to happen, and we had a system that was creating an opportunity for mistakes to be made,” says Mann, who led a multidisciplinary improvement group – comprised of physicians, nurses and pharmacists – in a process to examine the root causes for Logan’s medication error.

The result of the improvement group’s work is that potassium chloride has been removed from all acute care pediatric units in the hospital.

“General pediatric units can no longer make their own potassium infusions,” explains Janet Harding, Director of the Pharmacy Department. “Now, if a potassium chloride infusion is not commercially available in the required concentration, the pharmacy prepares it and provides it to the unit in a ready-to-administer format. We’ve also created standard work for the preparation of potassium chloride and a list for the types of solutions the pharmacy department will prepare.”

“It’s an agreed-to list of what will meet patients’ needs, so our healthcare providers are not trying to do complicated calculations quickly,” adds Doreen Zimmer, Operations Manager in the Pharmacy Department.

“One of the big learnings from this error is that there is no one owner of it,” Zimmer continues. “It needs a multidisciplinary, collaborative team, to really get to that next step in reaching safety, because pharmacy alone can’t fix it, nursing alone can’t fix it, physicians alone can’t fix it. If it’s simple, it’s already been done.”

“Logan’s experience completely reinforces why our focus for the next 90-day cycle is on patient and staff safety,” says Mann. “All of the improvements we’ve made since the medication error occurred are really important. I am so proud of how the entire team came together as a result of Logan’s experience to make our care safer. We’ve learned that no matter what situation we find ourselves in, we have to listen to both our staff and their patients and families to make safety improvements.”

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