Hospital "Error" Cited in Man's Death - page 3
I found this article "interesting" and it made me made....can someone tell my why the nurse "couldn't find help" and the MD blamed the death on her "guess". (Since I'm not certain of copywrite... Read More
Jan 18, '07Quote from kmchughGood catch, Kevin. Add me to your "me too" list.Something here is not right. I'd like to know more facts before jumping on the bandwagon.
Jan 18, '07This reminds me of another story in which the stab victim died because of hospital error. The murderer was acquitted because the hospital was found liable.
Jan 18, '07Quote from stevieraeHeparin IS available in 20,000 u/ml, as well as in 40,000 u/ml. Many hospitals do not keep these concentrations on their formularies, but they do exist. I am not aware of a 200 u/ml ampule, however...only 10 and 100 u ampules used for heparin lock. Still, if the hospital in question keeps lesser-used concentrations on its formulary, it is possible that the nurse thought that there may exist a 200 u/ml concentration and that it was what she had on hand (instead of 20,000 u/ml) so she decided to use it. Jumping to conclusions at this point, when all the facts are not yet known, is just that - jumping to conclusions. As others have pointed out, there are a lot of things about this scenario that do not add up and there are a lot more things that we just don't know because we weren't there.Still something wrong with the scenario.
I have NEVER seen vials or ampules or Heparin that were 20,000 U per cc.
For that matter, I have never seen vials or ampules that were 200 Units per cc.
So, how could she possibly have rationalized opening 5 vials to give what she thought was 1,000 Units?
And how could her eyesight have been that bad, to misread 20,000 U per cc as 200 U per cc? assuming such vials even existed, which I doubt, in either of those strengths?
Why would she have not accessed a SINGLE DOSE AMPULE of 1,000 U per cc?
Or a multidose 30 cc vial containing 1,000 U per cc?
Volume ALONE should have set off alarms in her head.
This gross negligence is indefensible.
Jan 18, '07My question is why would the nurse have administered anything without a specific dose order especially since she did not know it herself? Ultimately it was the MD's responsibility to give her direction in this situation. Whether he wanted to or not. She should've refused to give it without clarification. Emergency or not you still have to advocate for your patient.
Jan 18, '07Maybe this nurse added 100K units to the Pleur-Evac before sending the pt. to the OR and the mistake didn't harm the pt. until the blood pooling from the drain was washed through a cell-saver in the OR. An autotransfusion with overheparinized blood could possibly have happened at any time, and there's nothing in the articles to suggest how much was transfused.
Some posts on this thread have alluded to the idea that the nurse erroneously loaded a stab-wounded patient with a large volume of heparin (like a 50 - 100 cc bolus of straight heparin), but that wouldn't fit with the patient's alleged clinical course (... now I'm making assumptions); point being, we don't have anything other than a couple of newspaper articles upon which to base our ideas about what happened.
I'm not an experienced RN, but last year when I was being oriented to the trauma room, I asked a few experienced RNs about how to go about priming the Pleur-Evac drainage system for autotransfusion. Not one of them could tell me (I'll ask our clinical educator). The set we have for this purpose is in a plastic bag that contains a "wet" Pleur-Evac drainage system which has apparently not been used in at least 2 years because 2 years ago they switched to using the Pleur-Evac Sahara (the "dry" drainage system) exclusively.
I did ask if it was for Jehovah's Witness pts, but was told that religion doesn't even permit autotransfusion.
Jan 18, '07Thanks neuro23 for your empathetic consideration of the situation. It's not excusing the mistake but dismissing it as nothing more than carelessness misses many lessons to be learned.
No one sets out to make a mistake. We all do make mistakes sometimes. Usually we're lucky and we catch them before harm is done or no harm is done and we may never even realize we made the mistake.
There but for the grace of God....
Aug 24, '07now that i've read the whole thread...i had the same thought many of you did...something's wrong here, things don't add up. there's no doubt a mistake...or rather collection of mistakes were made. at first i thought the nurse shouldn't have given the heparin without a written order with an amount to give, or she should have refused to give it, and have the resident give it. then, i thought there seemes to be a policy/procedure for it...maybe there were standing orders...although, it is not sensible that the pharmacy and others wouldn't know how much to give if there was a written standing order...and they should have been able to find it...doesn't seem that was the case. i can't wrap my brain around how she thought she was giving and gave 1000 units, by drawing up 5 vials...but maybe that is not a correct report of the incident. i certainly can see how a person could be distracted while drawing up the heparin, and make a mistake that way. she was probably understaffed and overworked. i highly suspect that we do not have all the information...and it is being kept under wraps. i think:
-the nurse should not have given the heparin at all (maybe put a piece of tape on the pleurevac that had "no heparin added") and let or do it.
-the nurse should have insisted that the resident contact his higher-up because he wasn't sure of the procedure.
-i think more than 1 person should have been held liable for this error...definitely the resident and the person in charge of him, probably the or staff who may not have done appropriate labs during surgery (don't really know the facts there, though), possibly the pharmacy...don't know enough facts really. ya know, maybe something happened in the or that wasn't disclosed that had nothing to do with this nurse...she didn't even realize she had made an error at the time, maybe she really didn't and she's been brain-washed into thinking she did, badgered, and shown incorrect "evidence" such as heparin vials that were more units, and they weren't the ones she used, but the hospital is saying they are the ones she used...who knows? she probably did make an error, but we don't really know that at this point, and for sure she shouldn't be the only one at fault here...the resident comes blaring, to my mind!
and yes, when you are used to checking meds with another nurse (as we do in nicu for all our meds) if can get routine and careless...i've caught myself and co-workers agreeing things are correct when they are not on occasion.
something here is not right. i'd like to know more facts before jumping on the bandwagon. kevin mchugh[/quote]
Quote from neuro23thank you so much for that senario...mistakes usually happen when it's a bad situation, and frequently the person is trying desperately to do their best in an awful situation...that we'd all have trouble dealing with.imagine yourself in the trauma room when a resident gives you a seemingly simple order and says he'll be "right back;" you're unfamiliar with priming a cell-saver, but so is the resident. you call charge's cell ... "busy, please hold" ... you can't ... you call pharmacy; they're also of no help. you need to do something! you page the resident back, overhead. resident needs to consult his staff ...
as an rn, you want to help this patient so you get yourself together to find that the only cell-saver has illegible (blood stained) directions. you read what you can, go to retrieve the heparin but there's only 10,000 units/ml bottles available (even though you think you need 2-1/2 vials of 40,000 units/ml) ... so you draw up 10 into a 60 cc syringe and run back to the patient (after 3-4 minutes of reading and drawing up meds) ... you're now in unfamiliar territory ... you make a med error but the resident comes back to thank you for your "fine work;" the pt. needs to go to the or so you scratch down what was pertinent, e.g. "heparin added to cell-saver as per protocol ..." next, ems brings you a stroke in evolution ... could *easily* happen.
to the best of your knowledge, you have adhered to the six rights of drug admin. you don't know you've made an error so you go on to the next case. the nurse in the article could have been you. try to put yourself in her shoes ... was she trying her best to help a patient? did she seek help? have you ever drawn up several amps to get the right dose? i have.
literature supports that co-signing dosages does not decrease error rates -- it becomes routine ... more often than not, the "check" is but a glance at a loaded syringe that contains x units or mls of drug after the first nurse has checked the order or performed the calculation. the verifying nurse then initials, right?
rather than blame the nurse in the article, let's think about what we can do tomorrow to prevent a similar tragedy. we're in this profession to help patients. it is absolutely useless to post messages about how perfect we are (none of us is!) it is similarly useless to post messages blaming others. one person stated they wouldn't administer a med unless the dosage was written ... that's a useful point. what else can we learn?
my two cents: we can become excellent nurses only by focusing on our accountability to the well-being of our patients and by helping our colleagues achieve the same goal.
Quote from nightcrawleri found your comments very educational, sense i am not involved in that type of nursing, i didn't know some of this information, and it is rather interesting. as i said before, i don't think we have all the info...my question isn't with whether this was a med error, as of course it was, but more with why the error wasn't more immediately harmful. the second article stated that they had problems during the original surgery because of excessive bleeding. that i understand, the problem that i have is that heparin has a very short half-life.
working post cardiac surgery, we use heparin drips all of the time while pts with mechanical valve replacements are recovering and becoming therapeutic on coumadin, and we draw routine ptt's every 6-8 hours to ensure therapeutic dosage of the heparin. there have been many times when the ptt has come back very high, (usually near the beginning of heparin therapy)you turn off the drip, and the ptt is usually back down to therapeutic, if not all the way back to normal levels within three hours. ofcourse these people did not receive this high of a dose, but i have seen results in excess of 4500 seconds reverse themselves within 3 hours. if the problem was with the inital overdose of heparin, the patient never ever should have made it out of the first surgery, much less have died hours and hours later during a second surgery. heparin just doesn't hang around that long.
now, it sounds as if the heparin was added to a chest tube in the er, at least from what i have read. in that case, i would have to wonder if the patient was placed on heart/lung bypass during the initial surgery. pts on bypass are routinely heparinized to prevent clot formation within the machine and during surgery. if the patient did receive additional heparin throughout the surgery because no coags were drawn during the case, then i could see the effects lasting as long as they evidently did.. but if that was the case, then the harm came because no coags were drawn during the case when there was excess bleeding, or after the case to make sure that the patient wasn't in danger of continuing to bleed.
no argument here that the ed nurse made a huge mistake, but for there to be the results that there were in the patients course, it had to be just the first in a series of mistakes throughout the process.
just my thoughts, but it is often easiest to let the first chain in a series of institutional errors take the fall for all of the rest
Aug 24, '07there has to be more to this story. despite the excessive dose of heparin the drug is reversible and fairly short acting. Even if the docs didn't know the dose was too high if a patient got any heparin and then began to hemorrage protamine should have been given to reverse the heprin- the dose dependant on the aptt. I hope this comes out well for the nurse.