During my pediatric gen med rotation an error occurred to a patient that I was looking after and (with the nursing team) I was involved in reporting this to the PSLS system.
PSLS is the BC Patient Safety & Learning System which our site (SMH) utilizes to report errors that occur. The error that was submitted is a medication error. The error was that ceftriaxone was administered more frequently than prescribed (Q6H vs. Q24H). A total of 1.5 additional doses were administered over the course of the error, resulting in 2.5 times the dose that was initially prescribed (4000mg given vs. 1600mg prescribed).
Though the error was made in respect to administration, not dispensing or order checking by pharmacy, it was a great way to learn about the systems in place to help prevent these issues. In the PSLS we noted all the issues that arose. I learned that at each administration time the nurse administering the medication must check the MAR against the orders to ensure that nothing in the MAR was written incorrectly.
This was a great learning experience. The aspect that most resonated with me, was that although this was a serious error, there was a no-blame mentality amongst the team and that the appropriate reporting was done (both to the medical team, to pharmacy, and to the PSLS reporting).