Girl dies after medication error

  1. 4 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 old. The infection quickly spread through her intestinal tract and wreaked havoc on her tiny body.

    Alicia's doctors initially gave her a 5 percent chance of survival, said her mother, Dominique Coleman.

    Yet Alicia fought through 15 surgical procedures and the battery of medications that marked the first year of her life. She improved to the point where doctors wanted to wean her off her medications. She was learning how to walk.

    "We were very optimistic," said Coleman, 26, of Omaha.

    The 19-month-old child suddenly died Saturday while in the care of Children's Home Healthcare's World, a pediatric care center at 7815 Farnam Drive.

    Coleman and hospital authorities said medical staff erroneously injected some of Alicia's medication into a catheter connected to her jugular vein.


    full article: Girl dies after medication error - Omaha.com


    Unfortunately, the article is rather vague about the tragic medication error. From other news sources, the best I can piece together is that Alicia was to receive a "medication to slow her bowels" (Zantac? Paregoric?) It was to be given po/ng, but was admnistered into her central line instead.

    Apparently, the child usually had homecare services, but they were unavailable on Saturday, so her mother took her to the respite facility instead while she went to work. This facility is a part of Children's Hospital, which has an impeccible reputation. How terribly sad. Thisis the second deadly medication error involving a young child in our city in just the last few months. Another child died at the University of Nebraska Medical Center recently following an apparent heparin overdose.

    It is truly tragic that our health care leaders have been ineffective in preventing these errors. I believe in my heart that a large part of the problem is the lack of highly experienced nurses at the bedside.
  2. Visit  Jolie profile page

    About Jolie

    From 'Midwest'; Joined Oct '01; Posts: 9,301; Likes: 13,054.

    33 Comments so far...

  3. Visit  WalkieTalkie profile page
    2
    I was thinking something like lomotil or Immodium. I don't know. I seriously wonder if this is related to fatigue, inexperience, or what. It's unfortunate for everyone involved.
    cjmjmom and lindarn like this.
  4. Visit  Redhead28 profile page
    2
    Probably Reglan that can be PO or IV. Pushed the PO version.
    RNSC and lindarn like this.
  5. Visit  CrazierThanYou profile page
    1
    How sad...
    cjmjmom likes this.
  6. Visit  xoemmylouox profile page
    17
    Sadly everyone makes mistakes.. If the weatherman is wrong he can get up the next day - no harm no foul. If we mess up someone could die.
  7. Visit  angel337 profile page
    4
    the job of a nurse is so, so serious. i just hope that people going into nursing realize that someone could DIE at that blink of an eye if you are not careful. even after all these years i triple check everything especially on kids. my heart goes out to the family..
    Teresag_CNS, cjmjmom, Faith213, and 1 other like this.
  8. Visit  *LadyJane* profile page
    7
    Oh this is so sad.........

    Five rights... five rights, checked three times....

    every nurse should never get to the point where they stop checking the five rights.... three times....

  9. Visit  papa712 profile page
    19
    First off I would like to send the family my condolences... My ex wife works at this location and I just want everyone to know that they have a very good group of nurses who take there jobs VERY serious. Anybody could have made this mistake but I say let's pray together that this doesn't happen to any other family across the world. I don't know the nurse who did it but let's keep her in our prayers a long with the family of Alicia Coleman because this must be devastating for her and her family as well.
  10. Visit  ibeodo profile page
    0
    All said , they should investigate if the person involved is an RN indeed, and not another case of identity theft. We must do our best to provide safe and quality nursing to our clients at all times no matter how busy we are , if you need help please, please ask for it.
  11. Visit  JaredRN profile page
    0
    Interesting... I wonder what kind of facility this place is, and the acuity of patients. Do the nurses work with central lines often? Lots of questions, probably something very unusal happened.
  12. Visit  ♪♫ in my ♥ profile page
    3
    Quote from Jolie
    It is truly tragic that our health care leaders have been ineffective in preventing these errors.
    Our "leaders" can't prevent errors - only we, as individual nurses can prevent errors. And the reality is that no system and no person is infallible... errors will continue to happen, as hard as we try to prevent them.
    emnicams, talaxandra, and imintrouble like this.
  13. Visit  hdryder profile page
    0
    Cholestyramine (Questran) A drug used to bind with bile acids and prevent their reabsorption and to stimulate fat absorption.

    Very sad no doubt. The nurse must feel horrible. Pray for this nurse and the family.

    Sadly we dont know if the root cause is individual or a failure of the system. This is where just culture comes into play.
  14. Visit  imintrouble profile page
    0
    The ports on a central line look nothing like a Gtube. It sounds like what was meant for the Gtube was pushed into the central line. My worst nightmare x 2. A med error that would kill a pt. A med error that would kill a child.
    Following the tubing to the source should have alerted the nurse that the injection was not going to the stomach.
    My thoughts are with the nurse and the child's family.
    Last edit by imintrouble on Jun 2, '10


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