Doctor with syringe

Multi-agency and multidisciplinary problem solving: An increasingly common scenario in healthcare.

During an emergency C-section, under time constraint, the anesthetist intended to give the patient succinylcholine, however the drug given was actually cisatracurium. Both medications are used for muscle relaxation and paralysis, however cisatracurium has a much longer duration of action. Cisatracurium was available in the Labour and Delivery Suite, but the vial cap of cisatracurium had previously been blue, yet today it was red. This ‘medication error trap’ – a recurrent situation that predictably snares a large number of different people (Reason, 2004) – resulted in the patient having to be ventilated for longer than anticipated. The anesthetist immediately discussed this with the patient, while providing care. Although the clinical outcome was positive for both mother and baby, the mother required an extended period of anesthesia and mechanical ventilation with associated risks. After the event, the anesthetist promptly reported it in BC PSLS, which triggered a rapid regional review of drug substitution practices.

New Cisatracurium

New cisatracurium with red cap (second from left)

To learn more, BC PSLS Central Office met with Wrae Hill, Human Factors and System Safety, Interior Health (IH).

“Thank goodness the physician reported this event,” he says. “Previously, this type of case may not have seen the light of day. We are building a culture where clinicians are increasingly comfortable reporting system problems. So, it’s up to us to do something with these complex issues that may originate way up stream, far removed from the point-of-care. In this particular situation, we learned that this was a national problem. The challenge for all of us is to look at the whole system, from loading dock to loading dose, and attempt to correct what we can, given the constraints.”

IH Pharmacy leaders, Anesthetic Care Providers, Quality/Systems Safety experts and Supply Chain representatives opened an investigation into this event. Together, they identified opportunities to increase clarity and improve communication strategies for drug substitutions (Hill, 2016). This crucial step – of looking up and out rather than down and in – is often overlooked (Dekker, 2011).

The team learned about important systemic problems:

  • Drug substitutions and backorders are increasingly common. For example, in one year there were over 350 drug substitutions in BC’s supply chain, increasing the likelihood that clinicians may inadvertently make a medication administration error due to changing drug packaging.
  • Perioperative medication errors are more common than we might think. A recent prospective study revealed that these errors happen more often than previously reported in retrospective reports (Dekker, 2011; Nanji, 2016). Safety protocols that are common in other care areas (e.g. independent double-check) are not easily applied in anesthetic care.
  • No pictures of drug substitutions were included in the drug changes notification system; this oversight was identified as an opportunity for improvement at IH.

Creating drug change notices that, well… get noticed

Wrae explains that, “A constant barrage of ‘be really careful’ notices is ineffective. That’s just safety wallpaper and that form of cognitive clutter can be dangerous.  The challenge for us is to establish an effective notification system that will be seen and used by hospital staff. We asked clinicians, how should we target and disseminate this kind of information to different healthcare staff in such a way that they’ll see it? From a human factors point of view, we know that colour is a key identifier of medications, so access to comparative colour images, before and after changes, is imperative in these types of notices. Previously, notices did not include photos.”


Having identified areas for improvement, IH and Supply Chain co-created a new standard format for drug change notifications and backordered drugs, which now includes colour photos of the drugs involved in substitutions. All drug substitution notices are also pre-approved by a representative of the College of Pharmacists of BC. IH Pharmacy leaders distribute these notices to only those groups who need to know about certain drug changes. Distribution includes a PDF in a targeted email plus a colour screen shot in the body of the email to ensure the message is easily visible. The poster itself is printed in colour and placed in areas where clinical staff will see it, such as on the door of the medication fridge in the Operating Room.  

“This case presented a real learning opportunity for us. We need to be very mindful of what messages work for clinicians, and ask for their feedback. It’s an iterative process and it’s getting us closer to where we need to be.”

Drug Format Change

New Drug Format Change notices use colour and visual cues to highlight medication changes. Clinicians also provide feedback about other potential errors the change may cause.

Key takeaways:

  1. Pharmacists and buyers should specifically target messages to reduce information clutter.
  2. Use colour and visual cues to highlight (before/after) medication changes.
  3. Post notices where clinical staff are likely to see it.
  4. Seek feedback – clinicians are our eyes and ears. The new format specifically asks the clinician to provide feedback about any other potential errors the change might impact. (see Actions in Drug Format Change notice)
  5. Safety is a verb…it’s something we DO, not something we already HAVE (Dekker, 2011).

Improving Supply Chain communication practices presents only one example of the issues that are examined in a system approach to clinical risk management and safety event investigation. Opportunities to address other factors that support patient care and safety are ongoing across IH.


Dekker, S. (2011) Patient Safety: A Human Factors Approach. Boca Raton, Florida: Taylor & Francis

Hill, W. (2016, April 12) Applications of Resilience Engineering – Interagency coordination to anticipate and prevent Medication Error Traps [Web log post]. Retrieved from

Nanji, K.C., et al (2016). Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology, 124:25-34.

Reason, J. (2004). Beyond the organisational accident: the need for ‘‘error wisdom’’ on the frontline. Quality and Safety in Health Care, 13 (Suppl II), ii28–ii33.

Learn more about: Key Vulnerabilities in the Surgical Environment: Container Mix-ups and Syringe Swaps

Wrae Hill is a Respiratory Therapist with graduate training in Human Factors and System Safety. He reviews BC PSLS data to identify trends and themes to support quality improvement at Interior Health.

To learn more, please contact Wrae by email at

BC PSLS Central Office would like to acknowledge all those involved in this patient safety improvement at Interior Health. Your efforts are helping to improve patient safety. Thank you!

Pin It on Pinterest

Share This