[button2cute]

Hello All,

This Article was provided by AshRn, Today. The article present the deaths of three patients due to medication errors by nurses. Two were children and one was a 21 year old. Therefore, medication errors can kill a person and the prevention of medication errors will be a priority in this hospitals as well as others

http://www.mercurynews.com/mld/mercu...s/13117889.htm


Thanks, Ash for providing a very important article for all of us to read and contributing to the current events on the thread like every person has done.

Buttons

[West_Coast_Ken]

Originally Posted by button2cute

"...due to medication errors by nurses"

Nowhere in this article does the word "nurse" appear. It could have been a doctor, a pharmacist, or a nurse (or someone else).

Please be careful not to read into things. Sure, I know who administers most drugs, but again, the article did not lay blame on anyone other than their hospital.

Regards,

Ken

[TheCommuter]

Originally Posted by West_Coast_Ken

Nowhere in this article does the word "nurse" appear. It could have been a doctor, a pharmacist, or a nurse (or someone else).

Even worse, it could have been an unlicensed medication assistant or patient care technician who passed the lethal dose of medications. I heard that PCTs and medication assistants are assuming wider scopes of practice, which is bone-chilling.

[button2cute]

Originally Posted by West_Coast_Ken

Nowhere in this article does the word "nurse" appear. It could have been a doctor, a pharmacist, or a nurse (or someone else).

Please be careful not to read into things. Sure, I know who administers most drugs, but again, the article did not lay blame on anyone other than their hospital.

Regards,

Ken

Hello, Ken, Commuter and All

Yes Ken was correct in the article I had posted did not say "nurses". However, I found the articles that pertain to the article I had post. Yes, Ken and Commuter....the word "NURSES" are in the article and the nurses are alleged for the incidents. In addition, the Physicians are having their own troubles as well from the above incidents within the Kiaser's organization.

Please read the following:

www.kesq.com/Global/story.asp?S=4100600

http://www.mercurynews.com/mid/mercu...cal/1307913htm

http://www.kron4.com/Global/story.as...0&nav=5D7lBwNp

http://www.mercurynews.com/mld/mercu...h/13267923.htm

Ken, are absolutely correct...always find the original articles and place them.

Thank you for the encouragment Ken and Commuter to provide the original articles and not to accuse the wrong people such as medication assistants, PTCs, Pharmacists and etc.

Buttons

[Nicky032605]

In 1999 I went through Chemotherapy at Santa Teresa... and recieved a med dose. My Hickman Catheter was flushed with a steriod by mistake in the early morning. She had grabbed the wrong vial. Within a few minutes I was unable to breath, but they had gotten everything under control. Kind of a creepy thought as to what could have happend (besides the med dose I had recieved)...now that I see what is happening there now!!!

[Sheri257]

I have a question about this case cited in one of the articles:

June 2001
Patient admitted June 8 after breaking her hip in a fall at her nursing home. Patient had complained of constipation and was given a laxative June 13; a nurse also noted she complained of a tender abdomen. Patient was discharged to nursing facility June 13 but readmitted the next day with bowel obstruction, suffered renal failure after surgery, died June 16.
Deficiency: Nurse did not notify doctor or case manager of the change in condition of abdomen.
Response: Nurse said she did notify doctor but did not document that. Nurse retrained in notification.

So even if the RN did notify the MD about the tender abdomen and had documented it, is she still liable? The reason I ask is this article states RN's can be liable, even if the MD insists on discharging the patient in a case like this.

http://www.nurseweek.com/features/00-05/malpract.html

"You can’t just drop the ball," Higginbotham (the attorney) said. "You’ve got to go over (the physician’s) head and find somebody who’s going to give you orders to take care of that patient. Otherwise, you might find yourself in my office."

Is this true?

[KatieBell]

Med Errors are one of the things that is listed in the latest IOM report and indeed JACHO is going to have new regulations regarding that which include- taking the unopened medication into the room with the chart that has the order (not just a MAR) confirmation of birthday or other identifer, and then administration of medication. In the ED tis works pretty well, as the "chart" we have is just a clip board, but I can't imagine this in a nursing home/LTC facility.

[NRSKarenRN]

A chemotherapy patient died after his doctor mistakenly administered medication intended for another patient, state investigators found. Christopher Robin Wibeto, 21, died three days after a cancer-fighting drug called vincristine was improperly injected into his spine in August, the state Department of Health Services said Tuesday.

http://www.kron4.com/Global/story.as...0&nav=5D7lBwNp

In this case, physician at fault...

Originally Posted by lizz

I have a question about this case cited in one of the articles:

So even if the RN did notify the MD about the tender abdomen and had documented it, is she still liable? The reason I ask is this article states RN's can be liable, even if the MD insists on discharging the patient in a case like this.

http://www.nurseweek.com/features/00-05/malpract.html

"You can’t just drop the ball," Higginbotham (the attorney) said. "You’ve got to go over (the physician’s) head and find somebody who’s going to give you orders to take care of that patient. Otherwise, you might find yourself in my office."

Is this true?

Yes this is true: You’ve got to go over (the physician’s) head and find somebody who’s going to give you orders to take care of that patient.

When I first started my career 20+ years ago, had a night supervisor refuse permission to call attending at home (middle of night) after one of my respiratory patients was going down hill and intern's interventions weren't working. What saved my butt was I called ER doc and told her if not in room in 5 minutes patient was gonna die. Upon returning to room with IV solumedrol to push, patient had stoped breathing, I coded her and transfered to CCU.

Attending was furious. Pulmonary physician managing unit personally gave me his home phone number which I pasted in narcotic box back wall for safe keeping. Lot's of chart documentation over hourly calls to intern and supervisor. Sadly, patient died 3 days later.

Learned that lesson: go over heads to the top when indicated.

[Sheri257]

Originally Posted by KatieBell

Med Errors are one of the things that is listed in the latest IOM report and indeed JACHO is going to have new regulations regarding that which include- taking the unopened medication into the room with the chart that has the order (not just a MAR) confirmation of birthday or other identifer, and then administration of medication. In the ED tis works pretty well, as the "chart" we have is just a clip board, but I can't imagine this in a nursing home/LTC facility.

I realize that one of these cases involved a computer error but, something has to be done to computerize doctors orders with portable hand held systems. It's got to be more accurate that what a lot of hospitals have now. Every time I go through the chart to check orders the paperwork is spread out all over the place, it's never in chronological order, you can't read the handwriting ... it's always a mess. But there's no queston MARS are often unreliable because very few people actually check the MD orders. At the last hospital I worked the RN's only checked the MAR against the Kardex, which was not accurate either ... scary.

[ktwlpn]

Originally Posted by TheCommuter

Even worse, it could have been an unlicensed medication assistant or patient care technician who passed the lethal dose of medications. I heard that PCTs and medication assistants are assuming wider scopes of practice, which is bone-chilling.

and an rn/bsn could have been responsible...IMHO the most dangerous healthcare worker is the one that won't admit they are capable of making a mistake....