HS140 Unit 6 Medication Near Miss Seminar Reflection Example

Five Milliliters, Not Five Milligrams: A Unit 6 Seminar Reflection on a Near Miss With Concentrated Oral Morphine

[Student Name]

Purdue University Global

HS140: Pharmacology

Unit 6 Seminar Reflection

[Instructor Name]

[Date]

The scenario and classmates are composite and described by role; the safety model and lists cited are real.

The Scenario

The instructor presented a composite case from a hospice inpatient unit. A patient was ordered 5 mg of oral morphine solution every four hours as needed for pain. The unit stocked two strengths: a standard solution of 2 mg per mL and a concentrated solution of 20 mg per mL, used for patients who need small volumes. The order did not specify the strength. A staff member, reading "morphine 5" on the medication record and seeing the concentrated bottle in the drawer, drew up 5 mL. At the bedside, the barcode scanner flagged a dose mismatch: 5 mL of the concentrated solution is 100 mg. The dose was not given.

What I Thought at First

My first reaction was that the staff member had simply made a careless mistake. I said so in the chat. I assumed the lesson would be about double-checking. The instructor asked me to hold that thought until we had looked at every layer.

Moment One: Counting the Holes

The instructor introduced the Swiss cheese model, in which an organization's defenses are pictured as slices of cheese, each with holes, and an error reaches the patient only when the holes line up (Reason, 2000). She asked us to name each slice in the scenario and say whether it had a hole.

The order was the first slice, and it had a hole: it gave a dose in milligrams but no strength, so the reader had to choose. The stocking decision was the second: keeping both strengths in the same drawer for the same patient population made the wrong bottle easy to reach. The label was the third: a classmate who works in a pharmacy pointed out that concentrated solutions are labeled with a warning, but the warning is small and the bottles look alike. The staff member's calculation was the fourth, and the hole there was a confusion between milligrams and milliliters, a mix-up that textbooks single out for liquid opioids (Lilley et al., 2023). The barcode scan was the fifth slice, and it had no hole that day.

By the time the error reached the staff member's hands, three slices had already failed; the person was the last human layer, not the first cause.

Moment Two: The Barrier That Worked

A classmate who works as a pharmacy technician explained why the barcode caught the error. The scanner compares the product's code with the order. Because the order said 5 mg and the product scanned was 20 mg per mL, the system calculated that the drawn volume would deliver far more than ordered. She added that this works only if staff scan every dose and do not override alerts, and that alert fatigue leads to overrides when warnings fire too often for minor issues. The barrier worked that day partly because the unit had kept its alerts focused on serious mismatches.

Moment Three: Fixes Above the Person

The instructor then asked what would close the earlier holes. The group proposed three changes. Orders for oral liquid opioids should state the dose in milligrams and the strength in milligrams per milliliter, so no reader has to guess. Concentrated solutions should be stored separately, perhaps only in a locked bin for patients who need them. And oral syringes should be marked in milligrams for the concentrated product, so the volume drawn matches what the order says. Lists of error-prone designations already advise against ambiguous dose expressions (Institute for Safe Medication Practices, 2021).

What Changed in My Thinking

I arrived thinking a near miss was a personal mistake that someone got lucky enough to catch. I left seeing it as a system that nearly failed in four places and held in one. That changes what I would report. In my work at a pharmacy counter, I have seen prescriptions for liquid medicines written with a dose but no strength. Before the seminar I would have filled them with the strength we usually stock. Now I would call the prescriber, because that blank on the prescription is the first hole in the cheese.

What I Will Do Differently

I will treat any liquid opioid prescription without a stated strength as incomplete. I will also pay attention to where concentrated products sit on our shelves, and raise it with my supervisor if they sit beside the standard strength.

What I Still Wonder

I wonder how often staff override barcode alerts on busy shifts. If the one barrier that worked can be clicked past, the system's safety depends on how it feels to stop and check when the unit is short of staff.

References

Institute for Safe Medication Practices. (2021). ISMP list of error-prone abbreviations, symbols, and dose designations. Institute for Safe Medication Practices.

Lilley, L. L., Collins, S. R., & Snyder, J. S. (2023). Pharmacology and the nursing process (10th ed.). Elsevier.

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768