Changes in routines often increase the risk of mishaps.

rehearsed routines had to be changed. The result: an unanticipated mishap about a week after the new process was implemented. During morning rounds, a supplemental IV phosphate bolus had been prescribed for a critically ill 12-year-old child with a low phosphate level. Later that evening, the child’s phosphate level was extremely high. Despite aggressive therapy to correct the abnormal electrolyte level, the patient died the following day. It was then discovered that the child’s death was caused by an accidental overdose of phosphate. A dose of 25 mmol of phosphate (as sodium phosphate) had been prescribed. The standard concentration for sodium phosphate, as listed in the pump’s drug library, was 0.15 mmol/mL. With this newly established standard concentration, therefore, a total volume of 167 mL was required for a 25-mmol dose. An admixture procedure in a pharmacycompounding manual provided directions to make a stock supply of the standard concentration from which the 167 mL could be removed. The pharmacy technician did not realize that there was a new standard concentration for phosphate. He followed the former procedure of filling the order with the concentrated form of sodium phosphate taken directly from commercially available vials. The resulting product contained 167 mL of a 3-mmol/mL concentration of sodium phosphate (sodium phosphate dose = 501 mmol) rather than a 0.15 mmol/mL concentration (sodium phosphate dose = 25 mmol). Although the technician had used several vials for compounding, when the pharmacist checked the final product, only one partially used vial was present. Thus, the pharmacist assumed that the correct concentration of the product had been made. The error was not detected, and the product was subsequently dispensed to the nursing unit. From a nursing perspective, the nurse caring for the child could not have idenMr. Grissinger is Director of Error Reporting Programs at the Institute for Safe Medication Practices in Horsham, Pa. (www.ismp.org). Changes in Routines Often Increase The Risk of Mishaps