Too many, and then it was too late: how an enema mistake led to a patient’s death

It started as a routine order: two enemas, spaced an hour apart ahead of a procedure. By the time anyone realized something was wrong, the patient had received 23—and later died.In a new safety bulletin, the Institute for Safe Medication Practices Canada (ISMP Canada) described how a series of small system gaps, none technically catastrophic on their own, aligned to produce the fatal dosing error. The patient, an unnamed hospitalized older adult, had been prescribed sodium phosphate enemas to clear their bowel before a procedure. The drug is commonly used for that purpose, typically in a maximum of two doses, spaced 30-60 minutes apart, several hours before a procedure. Done correctly, it is effective and minimally invasive. But in excess, sodium phosphate enemas can cause dangerous electrolyte imbalances that can be fatal.In this case, the problem began when the prescriber modified a standardized electronic order set to match the timing of the patient’s procedure. The original order was meant to schedule two sodium phosphate enemas one hour apart—one at 10 a.m. the next day and another soon after at 11 a.m.However, while adjusting the order details, the prescriber accidentally removed the built-in instruction limiting the medication to two doses. At the same time, the computerized system retained the auto-populated start date as the current day, even though the administration times had been adjusted for the following morning. The stop date remained set for the next day. In effect, the order no longer described two doses, but a medication to be given every hour, for 23 hours. There were no alerts in the electronic medication systems to warn healthcare providers that the ordered dose exceeded the recommended daily limit. The resulting electrolyte imbalance was too much for the patient and proved fatal. ISMP Canada’s analysis pointed less to a single mistake than to a chain of design and workflow issues: besides there being no alerts to flag that the dose exceeded recommended limits, the system also did not clearly show how the order would play out once scheduled. And because the product was available as ward stock, doses could be administered without additional pharmacy checks once the order was in place.ISMP Canada said the incident reflected what is commonly known as “automation complacency”—the tendency to trust electronic systems are functioning correctly, even when something appears slightly off.To prevent similar incidents, ISMP Canada is urging healthcare organizations to take a closer look at how their systems are configured. That includes removing ambiguous frequency options from order sets, adding maximum-dose alerts and requiring stronger checks for high-risk medications. The institute also recommended actively testing electronic systems using real-world scenarios to see how errors might slip through.

Too many, and then it was too late: how an enema mistake led to a patient’s death

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