Informing pts/families of med errors; consequences?

  1. Greetings to all fellow nurses! My first time here so please bear with me. Looking for some input re: a life altering situation for me.

    I had a granddaughter born @ 24 weeks d/t my daughter having eclampsia. She weighed in @ 12 ozs. She seemed to be doing fairly well, all things considered; even gained up over 1#. We lost her @ 12 days old. Two months later, my daughter & I were notified to come to the hospital for the baby's "preliminary" autopsy report. At that time, the dr. informed us of a medication error; Vitamin A was administered IV instead of IM. He tried to reassure us that "there was no high levels of Vit.A found". First of all, we were shocked at just then being informed of the error. Secondly, referring to several resources, Vitamin A given IV "will cause anaphylactic shock and/or death." You can imagine how I feel, hoping for some sort of closure yet realizing what may have happened!

    Multiple questions in my heart & mind. Shouldn't families/pts be informed of med errors & by whom, the RN or MD? Should some sort of consequence be expected, possible depending on the severity of the error? Yes, I am a nurse & have made errors, which I feel horrible about & continue to learn from, but never with that type of consequence. Is this type of error "expected" to happen in a NICU? Aren't the nurses more specialized there? Should we consider legal action? It won't bring our little one back but could promote some patient rights issues?

    I will look forward to hearing from ya'll.
    Help this Grandma/nurse to heal.
    __________________________________________

    Do not fear death but of unlived life.
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  2. 12 Comments

  3. by   traumaRUs
    I'm so sorry for your loss! As to the error, was it not discovered until after death? (Perhaps through a chart review?) Just a thought. I'm not a NICU nurse, but I do know that (as you do) errors happen everywhere in the hospital. I do think the family should know and be notified when it is discovered. As to legal action - only you can decide that. Please take care of yourself.
  4. by   z's playa
    I was given MSO4 IM 15 minutes after telling the doctor I was allergic to it (hives, rash). He came back and realized the error and ordered the Benadryl. I asked for a copy of my chart and on it the error was documented and it read that I had been informed. All errors should be reported and documented. No matter how minor they may seem. That's what we're being taught in school anyways.

    I'm sorry to learn of your family's loss.
  5. by   Plagueis
    I am so sorry about your loss.
  6. by   NoCrumping
    Condolences to you, and of course your daughter.......

    Did they tell you that the Vit A was the cause of death? (or just that it was found on the chart... because it could have been charted wrong....)
    In all states I have worked in, a mistake, unless fatal or obviously altering..... is not mandatory repoprtable to pt or family.
  7. by   WI,RN
    Quote from z's playa
    I was given MSO4 IM 15 minutes after telling the doctor I was allergic to it (hives, rash). He came back and realized the error and ordered the Benadryl. I asked for a copy of my chart and on it the error was documented and it read that I had been informed. All errors should be reported and documented. No matter how minor they may seem. That's what we're being taught in school anyways.

    I'm sorry to learn of your family's loss.
    I do have a copy of baby's chart. I did find where the Vit A was ordered, given w/no mention of route given, if it was in error (which we are taught not to state "error"), the med DC'd, or if pt/family/dr notified. If there would be legal action, that is what my daughter wants to have as an outcome, patient rights to include informing of errors. In response to TraumaRUs, I do not know when the error was discovered! Yes, nurses are human, most (if not all) have made errors; I guess I feel that if I was that nurse, working with a common med given in the NICU, I would expect consequences if the result is/could be so serious. My psychologist is wondering if any nurses have experienced similar situations with a med error that have resulted in severe consequences....any input from anyone?

    And to all, thanks for listening. The short life of my dear granddaughter has certainly impacted my life....not sure if I know in what direction yet.
  8. by   CHATSDALE
    sorry about your loss

    determine if this was contributory to death of infant how close in time was the iv med to the loss of life .at the very least they [hospital-md] should inform family about what steps are being taken to prevent a future occurance

    the eclampsia is an issue also..we have a nurse whose last two babies have been delivered early d/t eclampsia...llittle girl is not doing well even after 8 months...she really feels quilty about having another after the first problem...tell dtr to have esp good prenatal care if she should decide to have another baby
  9. by   WI,RN
    Quote from CHATSDALE
    sorry about your loss

    determine if this was contributory to death of infant how close in time was the iv med to the loss of life .at the very least they [hospital-md] should inform family about what steps are being taken to prevent a future occurance

    the eclampsia is an issue also..we have a nurse whose last two babies have been delivered early d/t eclampsia...llittle girl is not doing well even after 8 months...she really feels quilty about having another after the first problem...tell dtr to have esp good prenatal care if she should decide to have another baby
    And that is part of my psyche that I am dealing with; I know life could have been quite difficult for my granddaughter, I am thankful she is not suffering. But I still miss having her. Thanks for the advice for my daughter; yes, she has consulted with the Perinatologists re: future pregnancies. Lots of food for thought there!
    We don't know the influence of the med error, it looks like it occurred 2 days b/4 her death. We have not followed up w/the hospital/staff re: preventive measures taken. I guess we need to be proactive....
  10. by   Jolie
    I am terribly sorry for your loss. As a NICU nurse, I cannot begin to imagine the grief and heartache I would experience if I made an error that resulted in serious harm or death to a precious baby! That is not to say that I have never made an error, but thank God, never one that seriously harmed a patient.

    In my experience, NICU parents are usually so very involved in their baby's care that it would be virtually impossible to keep an error from them, even if the staff were inclined to do so. I have seen situations where babies were harmed by nursing and/or medical errors. Thankfully, the docs and nurses were up-front with the parents. Usually the staff met to discuss the situation before approaching the parents. While parents were understandably angry and concerned with the quality of care and future safety of their infants, they seemed grateful to have the knowledge, and more inclined to be trusting of the staff in the future. To fail to own up to a mistake seems to be such a huge breech of trust, especially when it involves a fragile infant who can't advocate for herself.

    Does the timing of the medication error seem to indicate that it was a factor in the baby's death? Or did she die of apparently unrelated causes? I know the answer to this question won't ease your grief, but it does seem important in understanding the actions of the staff.

    Lastly, I applaud your family for trying to make something positive out of the death of your precious baby. I experienced a pregnancy loss that was directly related to a medical mistake made by the partner of my primary OB. It was heartbreaking to lose my first pregnancy, but I resolved to make sure that no-one else would suffer needlessly as I had. I met with the doctor who made the error. He genuinely expressed his sorrow, and we discussed how to prevent a similar mistake from ever happening again. Bless you all for having the strength to help prevent future errors that could cause another baby and family to suffer.
  11. by   WI,RN
    Quote from Jolie
    I am terribly sorry for your loss. As a NICU nurse, I cannot begin to imagine the grief and heartache I would experience if I made an error that resulted in serious harm or death to a precious baby! That is not to say that I have never made an error, but thank God, never one that seriously harmed a patient.

    In my experience, NICU parents are usually so very involved in their baby's care that it would be virtually impossible to keep an error from them, even if the staff were inclined to do so. I have seen situations where babies were harmed by nursing and/or medical errors. Thankfully, the docs and nurses were up-front with the parents. Usually the staff met to discuss the situation before approaching the parents. While parents were understandably angry and concerned with the quality of care and future safety of their infants, they seemed grateful to have the knowledge, and more inclined to be trusting of the staff in the future. To fail to own up to a mistake seems to be such a huge breech of trust, especially when it involves a fragile infant who can't advocate for herself.

    Does the timing of the medication error seem to indicate that it was a factor in the baby's death? Or did she die of apparently unrelated causes? I know the answer to this question won't ease your grief, but it does seem important in understanding the actions of the staff.

    Lastly, I applaud your family for trying to make something positive out of the death of your precious baby. I experienced a pregnancy loss that was directly related to a medical mistake made by the partner of my primary OB. It was heartbreaking to lose my first pregnancy, but I resolved to make sure that no-one else would suffer needlessly as I had. I met with the doctor who made the error. He genuinely expressed his sorrow, and we discussed how to prevent a similar mistake from ever happening again. Bless you all for having the strength to help prevent future errors that could cause another baby and family to suffer.
    Thanks for your response, especially being the NICU RN that you are.
    That is one thing we hear in this day & age of our litigous society; people are less apt to persue legal action & polls indicate honesty will get you everywhere! People want to be informed.
    I don't know the relationship of the med error in re: to baby's death. Difficult to determine too since she was on a vent. I believe the day of the error was the same day she had to be brought to surgery for a central line placement; she never seemed to bounce back after that. Of course, we still did not know of the error until 2 months after death.
    Since there was no father involvement, staying in the NICU was difficult 24/7 since my daughter was trying to recuperate postpartum/ post-eclampsia too. Sometimes, as a nurse, I feel I failed to 'save'/advocate enough for my granddaughter.
    Bless you for being such compassionate NICU nurse.
  12. by   heart queen
    I'm so sorry to hear of your grandbaby's death. I understand your need for answers as to why, especially with a medication error so close to her death. I only work with adults, yet this shouldn't change practice with med error reporting. Having worked in a few facilities, the practices do varry with alerting families. If I've forgotten a med and missed it, after speaking to the MD, I follow the orders, alert the patient (family) and monitor. Big errors are first treated, then discussed with risk management and a family notification plan is made. but they are still notified.

    Perhaps your wanting to prevent this from occuring again can lead you to meetings with the manager and pharmacist to change policy, and add education or whatever is needed.

    I've never been in your position so I can't honestly give a personal comment on litigation. As a working professional, I know that having made an error will scar my soul more than a jury verdict will.

    I hope that your search and decisions to act will bring peace to your heart.
  13. by   leslie :-D
    first and foremost, my heartfelt condolences for the loss of your granddtr.

    at the hospice where i worked, we were mandated to report to the md and the families if any med errors took place.
    i don't know if the state considers this mandatory or if it's per policy and procedures for ea facility involved.

    perhaps only a consult w/a healthcare atty will help you decide if you want to pursue litigation. since they're the experts of the law in this field, they'll tell you that either yes, there's a case or maybe/no because of other etiologies that could have caused your granddtr's death.

    God bless you and your dtr.

    leslie
  14. by   Jolie
    Since there was no father involvement, staying in the NICU was difficult 24/7 since my daughter was trying to recuperate postpartum/ post-eclampsia too. Sometimes, as a nurse, I feel I failed to 'save'/advocate enough for my granddaughter.
    [/QUOTE]


    Please don't allow yourself to think that you somehow failed your granddaughter! Deep down in your heart, you know that is not the case. You must allow yourself to grieve without placing guilt where it does not belong.

    The nurse made an error. Even his/her co-workers were not aware of it, or they would have prevented it from happening. How could any of your family members possibly have recognized it in advance?

    I had lunch with a dear friend today who recently lost her mother. She and I are both experienced nurses, as was her mom. She is blaming herself for failing to recognize an obscure condition that took her mom's life suddenly. There is no possible way she could have recognized this condition, but she still blames and questions herself.

    I pray that both you and my friend find peace.

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