[mystiqx]

I'm sure there is a bagillion threads out there on this. NY Times posted an article today (well yesterday since its 2 in the morning now) on it as well as the full 60 minutes segment on the Denis Quaid and family baby horror story. The segment is very interesting, and something that we as future nurses really need to take to heart, and why we need to keep all of our medication rights in mind in what ever we do.

I think this scared the bejesus out of me, as a future practising nurse, and it just makes me dread my Peds rotation even more.

http://well.blogs.nytimes.com/2008/0...ical-mistakes/


I hope you find this as interesting as I did.
~M

[jerzytech]

I just watched the "60 minutes" segment on this incident and have the same question that Dennis Quaid asked about the old heparin vials-why were they not recalled when the new bottles came out? True, the medicine in the vials was fine and not contaminated, but there were thousands of vials left in hospitals around the country, which means thousands more chances for this to happen again to someone else. Who know where the two medications were kept, if they were in drawers right next to each other or why the nurse didn't check the label? But I do agree that with two medications with the SAME NAME (just different versions), why did they both have BLUE LABELS to begin with?! One should be bright green or some other dright color, and one should be a darker and completely opposite color. I was even thinking the one the twins received by accident (10,000 units of heparin) on a peds floor should have a red label because its such a strong drug for a child to receive, and red would be an indicator to double-check the vial. So many questions going through my mind right now, many people are at fault (not just the nurse) and I wonder when medication errors will go down in number.

[ayla2004]

we had an incident in the UK where the Midwife hooked up the patients epidural to her perphial IV. mother died
even worse she denied that she did it.
the basics are check and recheck what you are giving.

[saali]

as i remember, our lecturer told us very scary stories about medication errors. in fact it is the most common medical error in all hospitals.
once my teacher told me a story about a little boy who recieved potassium instead of sodium chloride and died. all this because of not checking the 2 names properly by the nurse and because these 2 medications have the similar packet
so, i think it is better to check and check again than killing someone because of a little effort not done.

[Quickbeam]

I have some regrets in 20+ years of nursing but I have no regrets in the time I took to double check each medication, every time. I caught thousands of wrong meds, wrong doses, wrong routes and wrong patients. That's our job. Each med, each day deserves that kind of care and scrutiny.

[marikat534]

Not to be rude, but there are insulins that come in the same style bottle although they are not the same color liquid. (First thing that pops into mind is Regular and NPH) It is just as damn easy to mix them up. It takes 5 seconds to look at the bottle, 10 seconds to check it against the MAR! It is sad, but peds, snf, psych, icu, etc. no matter where you go, 5 rights is universal. It takes less than a minute to save yourself and the patient, a lot of misery.