A patient came to the emergency department with atrial fibrillation (AFib). Dennis Hudson, RN went to get Diltiazem, a medication to treat the heart rhythm disorder. He found a bag labeled Diltiazem. But it was filled with eight vials of Rocuronium, a muscle relaxant. The wrong medication did not reach the patient, because Dennis caught the error as soon as the medication bag was removed from the refrigerator.
One SafetyFirst expectation is to Pay Attention to Detail. Dennis was focused on the details at hand, thus avoiding an unintended error. By using the SafetyFirst technique of STAR (Stop, Think, Act, Review), Dennis avoided causing any harm to the patient. Dennis was recognized by the SafetyFirst committee for making a Great Catch!