AI Patient Safety Report

On October 14th, a pediatric oncology patient received a 200% overdose of heparin via continuous infusion due to a mathematical calculation error compounded by a lack of independent verification. The incident resulted in temporary anticoagulation management requiring vitamin K protocol activation, though the patient stabilized after 12 hours. Current workflow standards allowed for single-signature sign-off on pediatric weight-based calculations, which proved insufficient as a fail-safe. To mitigate future risk, Clinical Quality Management must prioritize an immediate transition to mandatory dual-sign-off protocols for all high-alert medications within the I.V. suite. This standardizes the verification process, ensuring that two qualified clinicians validate dosing accuracy prior to administration. Successful implementation requires updating the EMR alert system to enforce a secondary digital signature from a second nurse. Next steps include a policy audit of the oncology unit and staff retraining on high-alert medication safety logs.