Inattentional Blindness – Human Error that Costs Lives

A nurse pulls a vial of heparin from an automated dispensing cabinet. She reads the label, prepares the medication, and administers it intravenously to an infant. The infant receives heparin in a concentration of 10,000 units/mL instead of 10 units/mL and dies.

A pharmacist enters a prescription for methotrexate daily into the pharmacy computer. A dose warning appears on the screen. The pharmacist sees the warning, bypasses it, and dispenses the medication as entered. The patient receives an overdose of the medication and dies.

A nurse reaches into the refrigerator for a piggyback antibiotic for her patient. She reads the label, spikes the bag with intravenous (IV) tubing, and administers the medication to her patient. The patient receives a neuromuscular blocking agent instead of the intended antibiotic and dies.

A pharmacy technician labels and delivers an IV infusion to the dialysis unit. The nurse reads the pharmacy label and hangs the bag while preparing her patient for dialysis. The patient receives sterile water for injection instead of 0.9% sodium chloride and dies.

A nurse picks out a prefilled syringe of pain medication for her patient. She reads the label and administers the medication intravenously. The patient receives hydromorphone instead of morphine and experiences a respiratory arrest.

Read more about inattentional blindness here