What to do when something goes wrong: immediate patient care, disclosure, incident reporting, the systems (Swiss cheese) view of error, root-cause analysis, and practical safety tools — checklists, high-alert medication practices and a just culture.
At the bedside
Timed steps- 1
Make the patient safe
ImmediatelyTreat the consequence (e.g. naloxone for opioid overdose, glucose for insulin error), call senior help, monitor closely. Preserve evidence: keep syringes, labels, bags, device settings and logs.
- 2
Inform the consultant and be open
Same shiftTell the consultant in charge. Disclose to the patient/family honestly and promptly with the senior: what happened, what is being done, an apology, and what will be done to prevent recurrence. Document facts in the notes, without blame.
- 3
Report the incident
Within 24 hComplete the hospital incident report (including near-misses and 'no-harm' events). Reporting is about learning, not punishment. Serious events (sentinel events) trigger urgent review as per hospital/NABH policy.
- 4
Systems analysis
ReviewUse a structured review (root-cause analysis or similar): sequence of events, contributing factors (task, team, environment, equipment, organisation), why defences failed (Swiss cheese model), and actions with owners and deadlines. Feed back to staff.
- 5
Use proven safety tools
PreventChecklists (procedures, central lines, transfers, time-outs), standardised concentrations and pre-filled syringes, independent double-checks for high-alert drugs (insulin, potassium, heparin, opioids, vasopressors), tall-man lettering, separating look-alike/sound-alike ampoules, barcode/closed-loop prescribing where available.
- 6
Care for the 'second victim'
SupportStaff involved in errors often suffer distress; offer debriefing and peer support; a just culture separates honest error (console), at-risk behaviour (coach) and reckless behaviour (sanction).
Types of error (Reason) and responses
| Type | Example | Typical fix |
|---|---|---|
| Slip/lapse (execution) | Selecting the wrong syringe; forgetting a dose | Design: labels, separation, checklists, alerts |
| Mistake (planning/knowledge) | Wrong drug choice from knowledge gap | Training, decision support, senior review |
| Violation (deliberate deviation) | Skipping a checklist to save time | Understand why; fix workload/culture; coach or sanction if reckless |
| Latent condition | Look-alike ampoules stored together; understaffing | Organisational change |
High-alert ICU medicines — safeguards
| Drug | Typical error | Safeguard |
|---|---|---|
| Potassium chloride concentrate | Undiluted IV bolus | Remove concentrate from wards; premixed bags; infusion pumps |
| Insulin | 'U' read as zero; 40 vs 100 units/mL | Write 'units'; insulin syringes; standard infusion 1 unit/mL |
| Heparin | Confusion between 1,000 and 5,000 units/mL vials | Standard concentrations; double-check |
| Noradrenaline/adrenaline | Concentration and rate errors; interruption at syringe change | Standard dilutions; smart pumps; 'double-pumping' |
| Opioids/sedatives | Over-sedation, mg/mcg confusion | Use 'mcg' not 'µg'; sedation targets; naloxone available |
| Midazolam 5 mg/mL vs 1 mg/mL | 5-fold overdose | Stock one strength; label clearly |
After an error or adverse event
Step 1 of ~5
Patient first, then disclosure, reporting and learning.
Decision: Is the patient harmed or at risk?
Based on World Health Organization; Reason J. Educational use; follow local protocol.
Pathophysiology
Errors arise from the interaction of human cognition (attention, memory, fatigue, cognitive biases such as anchoring) with complex systems (interruptions, look-alike products, workload, poor design). Safety improves most when systems are redesigned to make the right action easy and the wrong action hard.
Evidence
- Reason (BMJ 2000): person vs system approaches to human error; the Swiss cheese model; high-reliability organisations expect error and build defences.
- WHO Surgical Safety Checklist (Haynes, NEJM 2009): 3,733 patients before and 3,955 after across eight cities (including New Delhi); mortality 1.5% → 0.8%, complications 11.0% → 7.0%.
- Keystone ICU (Pronovost 2006): checklist-based culture change abolished most CRBSIs.
- WHO Global Patient Safety Action Plan 2021–2030: seven strategic objectives including safety culture, high-reliability systems, patient engagement and learning from incidents.
- NABH (India): hospital accreditation standards include incident reporting, sentinel event review and medication safety.
Controversies
- Mandatory vs voluntary reporting; fear of litigation reducing reporting.
- Balancing a 'just culture' with accountability.
- Checklist effectiveness outside trial settings (e.g. Ontario surgical checklist study showed no significant mortality reduction).
🇮🇳 India notes
- Fear of blame and legal action (Consumer Protection Act cases) discourages reporting in Indian hospitals — leadership must visibly protect reporters.
- NABH-accredited hospitals must maintain incident reporting and sentinel event systems; ICUs should review incidents monthly.
- The Pharmacovigilance Programme of India (PvPI) accepts adverse drug reaction reports.
- Look-alike ampoules (e.g. different drugs in identical ampoules from generic manufacturers) are a common Indian latent hazard — segregate storage.
References
Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.