I recently made a mistake. Quite honestly, I am still very upset at myself for it and certainly not proud of it. In the name of education and supporting each other, I’m sharing it with you.
In recovery, I was preparing to give a patient a post-operative dose of Ketorolac: 30 mg, 2 mL. The vial I reached for on my countertop looked correct in size, color, feel, and clarity—2 mL, clear liquid, green cap, dark brown glass, white label. Everything looked right… but as I was conversing with the patient and because the intensity of the procedure was now over, I allowed myself to go into autopilot and I accidentally picked up midazolam. For years and years, I have used 50mg/10mL multi-dose vials. Due to supply chain issues, we had been switched to 10mg/2mL vials, and with the 10mL multi-dose vial being near empty, the next new vial (the 2mL vial) had been set out next to the 10mL vial. All this to say, I administered 10 mg of Midazolam, not 30mg of Ketorolac.
Fortunately, the patient did well. Protocols were followed. No harm came to the patient and all was documented. But that doesn’t mean no harm could have been. This was a sentinel event that I take full responsibility for. I failed to do the one thing that I HARP on to my team members and anyone that wants to learn with me. I called out what I was giving but did not double confirm the drug identity. This was a wake-up call that even the most experienced clinicians are vulnerable when systems allow room for error.
What We Know About Human Error
In the world of safety science, not all mistakes are the same. British psychologist James Reason developed one of the most influential frameworks on human error:
- Slips – You know what you’re doing, but you make the wrong move.
- Lapses – You forget something you intended to do.
- Mistakes – You form the wrong plan altogether.
- Violations – You intentionally depart from accepted procedures.
Most clinical errors, like mine, fall under slips—execution errors made while doing something familiar and routine.
LASA & Look-Alike Errors
In my case, the culprit was what’s known as a LASA (Look-Alike, Sound-Alike) drug error.
- Both vials: 2 mL, clear, brown glass, green caps
- No obvious label difference at a glance
- No tactile or visual cue to separate them
- One a sedative, one a non-opioid analgesic
This type of “description error” is well documented in patient safety literature. You perform the right action—but on the wrong object. In many cases, this happens when system design makes it nearly impossible to distinguish between choices.
Why Errors Happen – Even to Experts
Research consistently shows that human attention is fallible, especially during routine procedures:
- Familiarity breeds oversight – The more practiced we are, the more we operate on autopilot.
- Cognitive overload – Juggling multiple tasks increases slips and lapses.
- Environmental factors – Time pressure, fatigue, interruptions all amplify risk.
- Poor design – When labels or vials look nearly identical, even sharp eyes can fail.
Safety science emphasizes: “Human error is not the cause of failure—it is the symptom of a flawed system.”
Systems That Catch Errors
What could’ve prevented this?
- Distinctive labeling – Tall‑Man lettering, large bold drug names
- Color-coded bins – Organize look-alikes in separate, clearly marked trays
- Barcode scanning – Simple, effective confirmation at the point of administration
- Double-check culture – Normalize quick cross-verification with a second team member
We built Xchart to be one of those layers. Our checklists, visual prompts, and real-time vitals tracking are designed to catch small slips before they become sentinel events.
Final Thought: Vigilance Isn’t Optional
No one becomes a safer provider by simply “trying harder.” We become safer when our systems support us—visually, cognitively, emotionally.
This event didn’t change my commitment to patient safety. It deepened it.
Let it deepen yours too.
Stay sharp. Stay human. Stay vigilant.
Travis V. Coulter, DDS
Clinical Director, Xchart.com Travis@Xchart.com