Examining the complexity behind a medication error: generic patterns in communication

Communication was the most frequently cited cause of medication errors reported between 1995 and 2003. More detailed models of how communication breakdowns contribute to adverse events are needed to intervene to improve communication processes. We describe in detail an incident where an oncology fellow physician erroneously substituted the medication navelbine for the intended etoposide during ordering, resulting in a prolonged hospitalization with severe leukopenia for the patient. A team of human factors and medical experts analyzed the case and identified communication patterns described in the human factors literature. We discuss how the findings suggest targeted ideas for improving communication processes, media, and systems that may have higher "traction" for improving patient safety than are possible solely from aggregated analyses of coded descriptions of large sets of cases.