Patient dies from Intrathecal Vincristine - page 2
Australian Broadcasting Corporation TV PROGRAM TRANSCRIPT LOCATION: Broadcast: 05/05/2004 Hospital mistakes Reporter:... Read More
May 9, '04The belief that administering vincristine intrathecally is an error we should all feel sympathy for is for me a crock.
You are absolutely right I wasn't there because if I had been I would have stopped that idiot from injecting it into someones spine.
You are MISSING the fundamental point of my posting...he doesn't deserve ANY sympathy because IT WAS NOT a system error, it WAS NOT a pharmacy error...the medication ws clearly labelled VINCRISTINE aand if this person had ANY knowledge about the action of Vincristine on human tissue he would have known injecting it into the spine would be fatal.
There was NO ERROR here...the medication was clearly labelled...it wasn't pretending to be something else...this doctor had to remove it from its packaging...it was lazyness and ego. The fact that they arrived together is meaningless...they were clearly labelled medications.
Medication ERRORS are one thing...NEGLIGENCE is another...notice that cases of nurses that kill patients with the wrong drug are pretty rare... becasue we are trained to look at what we are doing.
I made a med error...a nurse before me didn't sign off her meds and I gave them again...this is an error.. the first nurse made a human mistake and because I didn't have enough experience or confidence to question why the drugs hadn't been given earlier and naively assumed she had NOT given them I compounded the error...thats a medication error.. we both reported it within 15 minutes of the drugs being given the second time and we both were very lucky that the patient suffered no consequences from our mistake. I learned to think critically and to ASK questions after that.
We knew what the drugs were and how they were to be given....we did not give a drug we had no clue about.
It is the ARROGANCE of that act that infuriates me.
You can skip your hateful little post about I can't wait for you to make your first med error...lovely post by the way...I can only imagine you cheering on peoples errors so you can pat yourself on the back and feel much better about your own...
I won't be the nurse that goes to jail because I was so arrogant I thought I knew everything and I didn't have to educate myself about any drug anymore because I'm perfect the way I am.
Be sympathetic when someone makes a system error or follows a doctors order out of inexperience only to discover later it was horribly wrong but never extend your sympathy to arrogance...that attitude needs to get stomped flat any time you see it.
Everyone you work with needs to be constantly encouraged to always ask questions...praise anyone who says "I am sorry I don't know but I will find out"
The very best nurses,doctors,aids know that asking questions is a sign of critical thinking and an interest in lifelong learning.
If that doctor had paid attention to what he was doing and who he was doing it to that error would have been avoided because the patient would have become a real person and he would have acted on the fact that he had no understanding of the drug he was about to inject.
ARROGANCE caused that error..not darkness , or both drugs together or a missing fatal warning...the doc gave a drug he had no understanding of, he made no effort to educate himself and he lazily injected it right into the same space he injected the methotrexate...he made no effort to report his error because he was so clueless he didn't even know he had made the error. It took someone else going through the chart to discover what he had done.
I save my sympathy for the nurse or doc who does everything right and the patient dies from an unknown drug allergy, that is a tragedy. I save my sympathy for the nurse who gets the IV antibiotics from pharmacy ,hangs it and the patient dies because pharmacy screwed up.
All my sympathy goes to the family and friends of anyone who is fatally injured because the people they trust with their lives are too arrogant to look after them with the care and attention they would give their family dog.
Maybe we should use that as the standard from now on...ask yourself..would I do this to or inject this into my puppy or kitten?Last edit by moia on May 9, '04
May 9, '04It is sad that this occurred but....
I have difficulty having a lot of sympathy.
Here, stateside Nurse get beaten over the head with the 5 rights of meds.
We get tied down with ID paperwork for checking blood transfusions.
And virtually in GOOD hospital requires that chemo NEVER be handled by nurses that do not know the consequences and are trained to handle the untoward events.
Do they teach these things to MDs and if not, why not.
An MD doesn't check the tissue type of a pediatric heart transplant patient and transplants the wrong type heart, causing the patient's death. WHY WAS THE TYPE NOT CHECKED?????
An MD amputates the wrong leg....and as a result, preop NURSES have to start right Yeses and Nos in marker to make sure that the DOCTOR doesn't screw up. Does it work???? Obviously not as the same idiot retains his license and manages to screw up again, by amputating a wrong extremity. And it still takes forever for the Board to pull his license.
And now an MD, working in a darkened room (mistake one - did he check the syringes before the lights went out - as nurses would do?) gave two syringes intrathecally (Did he read the orders...as every nurse that works with Vincristine would have?). And when the patient said that it felt wrong did he stop and recheck (as most Nurses are taught in school). And why was he giving a drug that he knew nothing about (something that would be an error in any Nursing School).
It is sad that medical schools do not hold future MDs to the same safety standards that virtually any nurse is required to uphold.
May 9, '04Quote from moiaSpare me the drama...The belief that administering vincristine intrathecally is an error we should all feel sympathy for is for me a crock.
IF you really read my post, you would see that at NO TIME did I state that the individual was not responsible for the error. Agreed??
AND if you took the time to use your "critical thinking" skills you profess to have you would give some thought to how these mistakes occur BEYOND the level of the individual. Humans are screw-ups, and we should try to make it MORE difficult for us rather than simply point the finger and say "It's YOUR fault" and walk away feeling all smug about ourselves because we didn't make the mistake.
Quote from moiaHuman mistake?? Hmm...she "forgot" to do something as important as signing off the meds given and was only in "error"...sounds like she was "negligent" and you were also since you relied on a "human" to perform their job without "lazyness and ego." It seems as though in your case it was only an "error" because nothing serious happened, whereas when the s**t really hits the fan, it becomes "negligence" due to "lazyness, ego and arrogance."I made a med error...a nurse before me didn't sign off her meds and I gave them again...this is an error.. the first nurse made a human mistake and because I didn't have enough experience or confidence to question why the drugs hadn't been given earlier and naively assumed she had NOT given them I compounded the error...thats a medication error..
Sure, you knew WHAT you were giving, but you DID NOT know that it had already been given. Didn't you see what time it was, and shouldn't the med have ALREADY been given?? Is YOUR inexperience any more of an excuse than the person who gave the Vincristine?? What if you had administered a fatal dose?? Would the nurse who didn't sign off her meds be guilty of only an "error"?? Would you??
We're all responsible for our actions and no one here is disputing that, so try using your critical thinking skills for something more than indignation and look for the many reasons why med errors happen.
May 9, '04Please keep to the topic and don't attack each other
Moia - what you don't know and can't know because you did not see the program was that the pharmacy had made up both doses in labelled syringes. He did not "have to remove it from the packaging"
I find I cannot agree with your views of medication errors. In fact it has been this type of attitude that has caused so many "hidden errors". that has caused the victimisation of the person instead of the analysis of the sytem. It has made shooting the people involved more important than preventing recurrance.
May 10, '04...I agree that systems need to be in place but it has become ridiculous the extent to which those in the medical profession will go to blame anything and anyone for their error.
If we took these errors as seriously as we should we wouldn't need a systems analyst to come in and devise a thousand different ways to prevent us from making mistakes.
Your very attitude arrogantly dismissing my response as "drama" shows the climate in which we work...outrage that someone KILLED someone is "drama" to you.
Yes..lets all drop the drama and outrage and have a committee meeting about how doctors should turn the lights on when reading labels, lets make sure Pharmacy adds giant red flashing fatal labels, lets make sure the drugs never get sent together....but lets not bother to make sure people who are responsible for drugs that could be fatal have to actually demonstrate any understanding of those drugs.
The vincristine error was all about knowing nothing about vincristine...the time and dose weren't in issue...the choice of route error was caused by a complete lack of knowledge about the drug itself and the complete disregard for the label.
We don't need more system analysts, we need everyone to stop rushing through the day..we need everyone to slow down, look at the patient and look at their reason for being in hospital and look at their meds...be honest when you dont recognize something and stop and find out.
A thousand system analysts can come into your hospital and arrange a system that seems foolproof...but if you are giving a drug you have no knowledge about no system will save you...you are the last line and if you cant bother you will find a way to subvert the very system designed to stop mistakes.
I have seen it already , a needle designed to fit only a certain way...I have seen doctors bypass it completely....knowledge is the only system that will work all the time.
.Just recently we had a nurse take one syringe of NS and one syringe of potassium to the bedside...her plan was to flush a saline lock and to add the potassium to an IV bag....ofcourse she made the decision that no labels were needed on those syringes and there was nothing wrong in shoving both of them in the same pocket
we can all guess the result..her patient died from a massive overdose of IV push potassium.
Do you see a system error? Do you think she was forced into this behaviour?
Do you feel sympathy for her?
We can say she wasn't malicious, she did not intend her patients death but everything she did wasn't a mistake...she defied every rule....this is an arrogant act no different from the docs. She didn't make a mistake.
People make genuine mistakes...they mistake one pill for another because the system for dispensing them is poor...this is a good place for a systems analyst to step in and say we can't keep doing this...we can all remember the board with the tiny med cups with the tiny strip of paper with the patients name on it... a recipe for disaster...we changed that so each drug has its own package with its own label...that system is fixed but it wont stop the uneducated from screwing it up anyway.
I have seen nurses take each med out of its package in the med room or on the med cart and put all the pills back into a tiny med cup and give that to the patient...the patient asks the nurse what is the purple pill and the nurse has no clue...we subvert every system in place constantly.
A simple way would to bring the pills in their packages to the bedside , open them in front of the patient and take the packages back to the med cart..ticking off exactly what we just gave...I can hear the howls already...we don't have time..we are understaffed..if I did that way it would be all day.....so what? Do it anyway...use the system put in place to protect your patient and you. Stop subverting the systems and don't give anything you don't understand.
You can learn from some tragedy, we can't learn anything from that doctors actions...we all know he broke every rule we have already learned...all I can feel is great sadness that we don't take real responsibilty for the harm we do...
It is terrifying that a med error is out there waiting for us and it may happen but your error should never be I had no idea what I was giving but I gave it anyway.
If you make an error admit it immediantly....almost always the patient can be saved from most errors.....
Can you think of anything so terrible and horrifying as to have given a drug a week before completely in error and it was discovered by a chart audit as your patient lay dying? To have walked and talked for a week blind to the fact that you have killed someone with your complete ignorance?
I think we should be outraged and demonstrate the rules we follow and our dedication to never making truly ignorant mistakes. We should be proud of how we were taught and share with everyone the rules that guide our practice.
We may never know if one doctor listened to our rules and applied them himself saving a patient from an error.
Our rules are good, they should be the benchmark for all medical practice.
May 10, '04It is amazing to me that a report of a doctor involved in a medication error STILL triggers nurses to attack each other. Let us walk away from this learning something.
We are all human
There but for the grace of god go I
Errors do occur when we are pushed into doing something unfamiliar without proper training and expertise
Let us be proactive in trying to make the system more foolproof - like only ever making up the vincristine in 100ml bags so that no one will think to give it the wrong way.
Lobbying pharmaceutical companies to ensure that the labels are clear and readable.
Changing the way that medicine is taught. At present too many post graduate medical courses in this country resemble institutionalised bullying rather than learning.
Let something positive come out of tragedy.
May 10, '04I think anyone who is in nursing for an extended period of time has made an error that could have been potentially fatal. That's because we are dealing with life or death issues all the time, every day, and just the laws of probability eventually catch up with us. The good nurses (and docs) admit their errors and then move heaven and earth to put things right, if at all possible. The bad ones ignore the chance to learn, and blow off patient/family concerns. That's the part I find disgusting about the scenario- not that an error was mad, although that is tragic, but that the hospital didn't learn from it happening to others before this incident, and take steps to prevent it. Plus they ignored the patient 's complaints of increased pain (unbelievable negligence).