Medication Error Experienced

Recently, I was asked to take someone to urgent care for the classic signs of a urinary tract infection with a fever that had gone from 100.3 to 102.3 throughout the day. Yep, time to go get some antibiotics! I’m guessing it is the same everywhere due to COVID, but only the patient is now allowed to go into the urgent care. So I waited in the car. The first update from the patient was the physician would be about 15 minutes. Not bad at all! While in the car I read a book and engaged in a couple different text threads and took a phone call. One of the text threads that was going was a group text with the patient communicating to myself and a few others on how things were going. Things were moving along in urgent care, and the latest was the option of an IM shot of antibiotics versus an IV and further blood work. The patient chose the most expedient, the IM shot. A text came in with a picture of a syringe. I took a quick glance and “oh, they are using a big syringe” went fleeting across my mind followed by, “the RN must have chosen that size to reconstitute” because the picture at first glance appeared to be the syringe just out of the packaging and waiting to be used. Back to my book and watching the empathetic responses from the group text.

A bit later the patient chimes into the group text that this was the most painful thing ever and because of their response to the shot there was concern about a possible anaphylactic reaction to the med (ceftriaxone). The patient needed to remain a bit longer so they could be monitored. We know IM shots are painful…. Ok. I have never had one or observed one being given so perhaps this is a common reaction. When the patient was released they were in clear pain when walking and it’s a good thing I have a SUV with very comfortable seats because I’m not sure how they would have made it home in a different type of car due to the pain in the buttocks! Once the patient was home and settled, they proceeded to give us the details of the visit and recount how horribly painful that shot was. They said, “I sent you the picture.”, which then sent a chill up my spine. I opened that picture back up and zooming in showed me that the syringe was full with a volume of 10 mls. No wonder the patient was in so much pain and had an anaphylactic like reaction. Sweaty, clammy, difficulty breathing, blood pressure changes and almost passed out! The maximum volume in the gluteal muscle is 5 ml and in the case of Ceftriaxone 1g it should have been 4 ml if reconstituted according to directions of 250mg/ml. Try to imagine how horrible I felt. I could have prevented this error if only I had zoomed into the picture earlier! Ugh!

Below is a picture of the actual syringe used:



I worked with the patient to craft an email to the provider and make them aware of the error. We expressed our concern of this type of error in an urgent care setting especially where IM shots would be the norm. Two days later the provider responded to check in with the patient of how they were feeling and made no mention of the medication error! That took me from frustrated this error happened to downright angry it happened and we were being ignored. Those of us with risk experience always hear, a simple apology can avoid many grievances. Now I have been on that end. A formal grievance has been filed and in true Medication Safety Officer form they have been given a list of 6 things needed for us to consider “a proper solution to the issue”.

When you make a mistake, there are only three things you should do about it: admit it, learn from it, and don’t repeat it. — Paul Bear Bryant

Terri Vidals
Terri Vidals

Terri has been a pharmacist for over 30 years and is a drug diversion mitigation and monitoring subject matter expert. Her years of experience in various roles within hospital pharmacy have given her real-world insight into risk, compliance, and regulatory requirements, as well as best practices for medication and patient safety.

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