Girl dies after medication error - page 4

by Jolie 23,156 Views | 33 Comments

Alicia Coleman was born relatively healthy, her mother said, even though she was three months’ premature and weighed little more than 2 pounds at birth. Things grew worse when Alicia came down with a bowel infection at 12 days... Read More


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    I know at my facility we have NJ tubes that you have to use a luer lock with an adapter to administer meds through them. You can't use the oral syringes on them. I can see where you get the meds ready, have some to give IV, some to give via the J tube, it could be quite easy to grab the wrong one if you get distracted.
    And I have to agree with those saying that nobody is perfect. If you're throwing stones here, you either haven't made a med error YET, or you don't realize that you already have.
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    This is so sad
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    Quote from carolinapooh
    I hate to say this, but given some of the stuff I've been told by RNs in transfer reports, such an error would not surprise me (and I can give a LOT for human error).

    I got report one night from a medical floor - a cancer patient of ours was being transferred down to our unit since we'd just had a bed become available. The patient had a right chest wall port. The RN told me, "Well, we accessed his port but we're waiting for a chest xray to make sure it's OK to use."

    Alarms went off in my head.

    I happened to have the patient's med record open on the computer in front of me, and as I flipped through it I asked the RN if the port was new (I thought I recognized the patient and if I was right, the port WASN'T new). She said no, but they had to wait to check for placement.

    I then asked her what kind of needle they used to access the port, and was relieved to hear they'd actually used a Huber (I heard about a patient that the staff had tried to access the port with a STANDARD 18 gauge - no, no, no - they ended up severing the port tubing with all the jabbing and a five inch long piece ended up in the patient's PULMONARY ARTERY!!). I told her that you don't order a CXR for an old port because the ports are placed by interventional radiology and the placement is confirmed at insertion. The only thing you ordered a CXR for (at this particular place) was a PICC line. And anyway, whenever a port is placed ANYWHERE placement's checked at insertion, whether IR put the thing in or not. Once it's in, it's in, and they recheck it if it's a problem or if it's potentially flipped or whatever.

    This is the answer I got. "Oh, yeah, well, we figured you guys would know more about it anyway." (Then why, pray tell, did you touch it in the first place??)

    My point is, if you don't know what you're dealing with (and there's no shame in it), ask before you use it.

    The last sentence sums everything up! A scary nurse to me is one who never asks questions and assumes to know it all and then cause harm to others. A good nurse, to me, is the nurse that continues to ask questions every day. The day I know it all is the day I want someone to show me the door and kick me out of the hospital.
    labrador4122 likes this.
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    Quote from imintrouble
    I have never seen a nurse deliberately make a med error. I have never seen a nurse not berate themselves when they do commit a med error. I've seen some nurses grieve for days, when something they've done harms a pt. I can only assume those of you throwing big fat stones must have NEVER made a med error. Either that, or you're not a nurse. Making an error humbles you. Reminds you that you're not perfect, and never will be.

    I am not angry at the nurse who is responsible for the little girls' death. She is already living a hell I cannot imagine. To those of you who are feeling superior and infallible, you're not.

    I am saddened by the child's death. My thoughts are with her mother, as I am a mother myself. I have compassion for the nurse, as I am a nurse too.
    I totally agree with you!
    Once when I missed a medication, my manager told me like I was an idiot "remember the 5 rights"......... and I just remember feeling very embarrased at the way he talked to me.
    I am not saying that I do not make mistakes now, but I have and yes, just like you said, I feel terrible afterwards just like anyone else would.
    I really am super careful when giving IV and PO meds, and check my ID bands before administering.
    but I agreed with what another post said-- if you mix something with tap water do not put it in a central line-- any prudent nurse should know that.


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