Background: In a series of cases that came to be recognized as a national methanol outbreak, an incident of delay in allocation and treatment with the antidote fomepizole is described with aim of sharing a learning experience.Method: A team of 16 members was formed to conduct a Root Cause Analysis (RCA), which included multiple individual interviews with the stakeholders and inspection visits to the area.Results: Root causes: The restocking process was unclear and inconsistent and specifically lacked a restocking policy for antidotes, inappropriate labeling and area design, and a sound-alike between fomepizole and omeprazole. Contributing factors included: unsuitable restocking practice and lack of training in using the pharmaceutical electronic inventory system. Corrective actions were recommended and implemented.Conclusion: Management of antidotes in large healthcare systems requires a team effort to ensure appropriate and timely availability in emergency poisoning cases. This RCA identified important areas for improvement that could be insightful to other institutions in preventing similar vulnerabilities and is unique in describing the details of system improvements that can have a large impact on patient safety.

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Background Medication errors remain the leading cause of mortality and morbidity in the pediatric emergency room (ER) across the world. The Institute of Medicine (IOM) has noted that this is due to the unique needs of the pediatric population compared with adults. With the introduction of the Computerized Physician Order Entry (CPOE) system in the National Guard Health Affairs (NGHA), there was a decrease in medication errors resulting from prescription. Inevitably, the CPOE did not eliminate all prescription errors. The King Abdullah Specialist Children Hospital Emergency Department reviews all safety reports (SRS) as part of the daily key performance indicators meeting with the ER Chairman, nurse managers, and charge nurses. The SRS report from 2016 showed a total of 102 errors. Medication administration is a process that commences with prescription by physicians, then dispensing by the clinical pharmacists, and finally administration by nurses. The NGHA adheres to the 'swiss cheese model' recommended by its Safety Medication Program; therefore, the majority of these errors were 'near miss', meaning they were caught in the process before reaching the patient. The aim of this project was, therefore, to reduce the rate of prescription errors by 60% by the end of 2018. Methods This project was done in the KASCH Emergency Department with a total of 65 beds. Total visits can be up to 500 patients in 24 hours, especially during the winter season. PDSA (plan-do-study-act) methodology was applied in this quality improvement project. A collaborative team was formed led by the ER Chairman. A series of meetings were held. Cycle 1: team formation, brainstorming, and data validation and analysis. The following themes were identified: dose incorrect, frequency incorrect, and allergy override. The following medications were also identified with frequent errors: paracetamol, dexamethasone, and antibiotics. Cycle 2 focused on establishing order sets, pre-calculated prescription doses based on weight on BestCare. Cycle 3: allergy awareness campaign to all clinicians. PDSA 4 focused on the accuracy of reporting errors follow-up and action plans to be implemented and documented. Results The overall results showed that there were 28 ER prescription errors in the year 2018 compared with 102 in 2016, reflecting a reduction of 73%. Conclusion The success of this project was evidence that collaboration among all clinicians involved in medication administration can greatly decrease medication errors. This project aims to spread to all areas of KASCH to address the challenge of medication errors.