insulin given instead of heparin to infant? - page 3
In this medication error, insulin was given to an infant instead of heparin. This means only that the person who gave it did not check the label, therefore did not follow the 5(or more) rights. ... Read More
3Dec 10, '11 by llg, BSN, MSN, PhD GuideThere are many research studies that show that people make mistakes when they are busy, stressed, tired, distracted, and/or multi-tasking. Even though they look directly at the label and "read it," their brains play a trick on them -- causing them to actually "see" what they expect to find there and not what is actually printed on the label.
That's why the current thinking among experts in error prevention programs stress the implemenation of systems to minimize the chances of error -- and not just the punnishment of the people who make the mistakes.
If you would like to read some of this research ... search under terms such as "inattentional blindness," "distractions," etc. as well as under "medication errors" and similar phrases.
1Dec 10, '11 by Esme12, ASN, BSN, RN Senior ModeratorWhat safe guards have been put in place here may not be the norm in Canada. The article didn't even mention if it was a nurse....it could have been pharmacy or a pharm tech, since the same mistake was on 4 other infants. The article clearly indicates that the baby died from pneumonia although I am sure the stress from the low blood sugar didn't help the babies recovery.
Like someone else said (ooh) we have all made mistakes and a major majority of us are very lucky there wasn't a bad outcome......But for the grace of God go I. How horrible for all those involved.