Table 2.

Case scenarios used in the PERCS-Medical Error workshop.

Case scenario I—Massimo Pecca		Case Scenario II—Lucia Molteni
Massimo Pecca is a 65-year-old man hospitalized for a lung lobectomy due to a tumor of the lung. After surgery, the physician orders an infusion of morphine for pain management at 1.0 mg/h, using the “trailing zero”, a practice prohibited by hospital policy. The nurse, not accustomed to the trailing zero, reads the order as 10 mg/h, not the intended 1 mg/h. The nurse calls the physician to express her concern about the high dose and asks the reason for such a high dose, without specifically mentioning the actual dosage. The physician replies that the dose he ordered (1 mg/h) is appropriate for the intervention. The nurse then starts the infusion at 10 mg/h precipitating a respiratory arrest and transfer to the ICU. After admission in the ICU, Massimo recovers completely. The physician and the nurse meet with the daughter, while Massimo is recovered in the ICU, to communicate the error.		Lucia Molteni is a 41-year-old woman who has been hospitalized for a caesarean section. On the first post-partum day, the physician advises a transfusion of two bags of blood components due to blood loss (around 900 cc) and anemia. The patient agrees to the transfusion but asks that the bags be covered because of an aversion to the blood. The nurse submits the physician’s request to the transfusion center, where only one operator is present. The transfusion center operator, being the only two bags required in the morning, delivers the bags without checking them. The nurse having asked for Lucia Molteni’s bags, takes the bags without checking the name of the request and performs the transfusion by covering the bags as requested. After a while, Lucia begins to feel unwell, trembles, and sweats, and the doctor decides to suspend the infusion. The patient receives 1 gr of flebocortid and 1 mg of a benzodiazepine, with an immediate resolution of the symptoms.  Upon discarding the bag, the clinical team realizes they have administered blood to Lucia which is incompatible with blood type. The patient’s change in renal function parameters is so compromised that it requires treatment of two sessions of dialysis. The healthcare team have to communicate to Lucia the error and the new treatment required.

Adapted from Troug et al. [21].