1. What happened?: Begin by understanding the sequence of events leading up to the sentinel event. Gather detailed information about the incident, including the timeline, people involved, and context.
   • Who did the problem/event affect, and how?

A 72-year-old female patient admitted for heart failure was administered a double dose of furosemide (Lasix) within a 2-hour interval. The repeated administration caused sudden loss of fluid and electrolytes, which resulted in severe hypotension and arrhythmia. It called for transfer to the ICU for stabilization.

Understanding What Happened

1.              What happened?

The incident occurred during morning meds on a med-surg floor. At 0600, the night shift had administered furosemide 40 mg IV but failed to document in a timely manner due to lagging electronic health records (EHR) systems. For the shift change at 0700, verbal handover included “morning meds administered” without listing the specific meds completed. The day shift nurse, who had eight patients due to understaffing, read the undocumented EHR at 0800 and administered a second dose of 40 mg furosemide. At 0930, the patient experienced severe hypotension (78/45 mmHg), arrhythmia, and required the response team to intervene immediately and also to be transferred to the ICU.

Who was affected: The patient needed a 48-hour ICU admission due to hemodynamic instability. Both nurses were emotionally distressed and took part in a formal debriefing.

1. Why did it happen?:
   • Human Factors: Investigate whether communication breakdowns, staff fatigue, or lack of training contributed.
   • System Factors: Examine workflow processes, equipment failures, and environmental factors.
   • Organizational Culture: Assess if there are cultural issues, a lack of safety culture, or inadequate leadership support.
   • Society/Culture: What role might cultural assumptions or backgrounds play?

·       Human Factors: Unstructured shift handoff led to communication failure. Consecutive shifts of work led to fatigue in the nurse, resulting in lowered cognitive alertness (Manias et al., 2021). Time pressure due to understaffing led to shortcuts in verification.

·       System Factors: Inconsistent medication reconciliation processes between shifts existed. The EHR system lacked duplicate dosing alerts for high-risk drugs. There was no double-checking system mandated for cardiovascular drugs (Koyama et al., 2020).

·       Organizational Culture: Pressure to be effective under conditions of staffing shortages, entrenched workarounds. Less emphasis on questioning incomplete documentation when time constraints were present.

·       Society Culture:  Staffing cost control pressures created staffing models that doubled workload per nurse. Cultural presumptions of individual nurse accountability rather than system-based safety measures governed the reaction to medication mistakes. The professional nursing culture emphasizing autonomous decision-making may have hindered seeking supervisory consultation when the medication history was unclear.

1. Was there a deviation from protocols or standards?:
   1. Procedures and Policies: Determine if established protocols were followed or if there were deviations.
   2. Were any steps that were not taken or did not happen as intended?
   3. Documentation: Review medical records, nursing notes, and other relevant documentation.

a)     Yes. Hospital procedures require complete documentation of medication within 30 minutes of administration, which was not accomplished. Medication reconciliation policies require verification of high-risk meds during shift reporting, which was avoided.

b)    Steps not taken:The day shift nurse failed to reach out to the previous nurse when the history of medication was unclear in the EHR.

c)     Documentation: Partial entry of furosemide during the night shift was discovered in a review of medical records and nursing notes. This inappropriate documentation misled the day shift nurse, directly contributing to the duplicate dosing error.

1. Who was involved?:
   • Staff: Identify the roles of individuals directly involved in the event.
   • Supervisors and Managers: Investigate

Staff: Day shift registered nurse (5 years of experience) who administered the same dose twice; Night shift registered nurse (8 years of experience) who failed to complete on-time documentation; Charge nurse available but not asked for input; Unit pharmacist available but not involved in bedside confirmation.

Supervisors and Managers: The Charge nurse was available but was not consulted about the medication history, a missed opportunity for supervisory guidance. The unit manager was only notified after the event rather than being involved in active problem-solving. Managerial distance from high-risk settings contributed to independent decision-making in the absence of organizational input.

1. Was there a breakdown in communication?:
   1. Interdisciplinary Communication: Assess how well different teams communicated.
   2. Patient-Provider Communication: Explore whether patients were informed and understood their care.

a.     Yes. The verbal handover was not in formal SBAR form, leading to poor transmission of critical medication information. Formal handover processes significantly reduce medication errors and breakdowns in communication (McCarthy et al., 2025). There was no standardized process in place for checking incomplete medication files between shifts.

b.     Patient-Provider Communication: The patient was not informed of the drugs given to them during the night shift, missing the opportunity for patient confirmation of drug administration. Research indicates that involving patients in medication reconciliation will serve as a second safety check and reduce administration errors (Manias et al., 2021). The patient was not educated on the different drugs she was on, or asked to speak up in case of duplicate doses given.

1. What were the contributing factors?:
   • Physical Environment: Consider facility layout, equipment availability, and workspaces.
   • Staffing Levels: Evaluate if staffing was adequate.
2. Training and Competency: Assess staff’s knowledge and skills.

·       Physical Environment: Separation of the medication preparation area from the computer workstations created workflow interruptions. High levels of noise during shift change created distractions.

·       Staffing Levels: Staff worked at reduced capacity due to call-ins, nurse-to-patient ratio of 1:8 rather than recommended 1:6.

7.     Training and Competency

 A comprehensive medication safety validation that was recently done occurred 14 months prior. No recent training on EHR safety features or managing medication discrepancies. Limited training was reported by some nurses about duplicate dosing cautions in the EHR system. This knowledge gap in continuous education likely contributed to the error, as given the circumstances, the nurse might not have been too much confident in the available safeguards.

1. Did organizational policies or procedures play a role?:
   • Policy Compliance: Investigate if policies were followed.
   • Policy Clarity: Assess if policies are clear and accessible.

Compliance: Yes. Medication reconciliation policy requiring confirmation of high-risk medications was not consistently implemented. Incomplete EHR documentation process lacked specified steps and chin of command.

Clarity: Policies were relegated to online portal that took multiple clicks, creating access barriers during busy times.

1. Was there a failure in monitoring or surveillance?:
   1. Vital Signs Monitoring: Check if there were any missed signs.
   2. Alarm Fatigue: Explore if alarms were ignored.

a.     Yes. No routine vital sign monitoring scheduled between 0800-1000, in the absence of early hemodynamic changes. No automated duplicate dose warnings in EHR system. Early symptoms were not immediately recognized as medication-related.

b.     Alarm Fatigue: Although the EHR and monitoring systems had routine alerts, staff admitted that frequent non-urgent notifications caused  themto be less responsive. This ‘‘alarm fatigue’’ likely contributed to the duplicate medication not being responded quickly.

1. What can be learned to prevent recurrence?:
   • Lessons Learned: Identify systemic changes, training needs, and improvement opportunities.
   • Quality Improvement: Consider implementing preventive measures.

Lessons: It can be learned that standard handoff protocols using SBAR format are critical to prevention of duplication error (McCarthy et al., 2025).

Measures: Some of the measures include duplicate dose alerts that are technology barriers can reduce human error when implemented correctly (Mulac et al., 2021). Adequate staffing and adequate rest breaks are critical in prevention of fatigue error (Manias et al., 2021).

1. How can patient safety be enhanced?:
   1. Risk Mitigation: Develop strategies to minimize risks.
   2. Education and Training: Ensure staff are well-trained.

1. Reporting and Feedback: Encourage open reporting and learning from mistakes.

a)     Risk Mitigation: Mandate SBAR communication format for all handoffs of medications to minimize communication errors. Use EHR-based duplicate medication alerts with time parameters for high-risk furosemide medications. Create independent double-check policies for cardiovascular meds. Implement standardized medication reconciliation procedures with clearly defined verification requirements at shift change.

b)    Education and Training: Provide annual competency verification of medication safety practice for all nursing staff with simulation-based scenarios. Conduct quarterly safety huddles on medication error prevention and lessons learned. Provide just-in-time training modules on new EHR safety features and duplicate dose alert systems. Develop interprofessional education programs with nursing, pharmacy, and physician collaboration.

12.  Reporting and Feedback

Establish a non-punitive error reporting system which encourages reporting of near-miss events and medication discrepancies. Create regular safety rounds to discuss medication-related incidents and share improvement strategies between units (Chance et al., 2024). Initiate peer review processes for medication errors with focus on system improvement, rather than blame. Create feedback mechanisms to let personnel know the results of safety improvement initiatives and celebrate successes in preventing errors.

F/S

2.     Incomplete EHR documentation and lack of alerts.

3.     Nurse fatigue due to staffing shortages.

One for each Root Cause/Contributing Factor from above

Choose one

·       Required SBAR handoff document with detail medication fields.

·       Isolated double-checking requirement for high-risk meds.

·       Documentation in real time within 15 minutes of drug administration.

·       Trained bedside verification with patient affirmation where necessary.

Professional Development

·       Annual medication safety competency verification for all nursing personnel.

·       Monthly safety huddles with an emphasis on error prevention.

·       Just-in-time training for new technology projects.

·       Interprofessional communication education.

·       Eliminate repeat med errors with high-risk meds in 6 months.

·        Achieve compliance with SBAR handoffs in 3 months.

·       Have EHR repeat dose alerts implemented in 4 months.

·       Reduce nurse fatigue reports through improved scheduling in 6 months.

Implementation Timeline

·       Weeks 1-2: Staff training on SBAR process and policy updates

·       Month 2: Preparation and installation of EHR system upgrade

·       Month 3: Full roll-out of technology controls with surveillance

·       Month 6: Comprehensive assessment and process refinement

External Resources: Medication safety consultant for assessment and recommendations ($15,000). EHR system enhancements for duplicate dose warnings ($25,000). Communication training specialist to implement SBAR ($8,000). Additional barcode scanners and mobile terminals ($10,000).

Resource Leveraging: Utilize the existing simulation lab to provide training scenarios. Work with the nursing professional development committee to incorporate competency. Collaborate with regional healthcare networks to share best practices. Establish academic partnerships for upcoming research and innovation.