From the Sun-Sentinel:
-ER nurse, with 9 years experience, is caring for a 44 y.o. F patient, c/o seizure with hx of same. The patient ran out of Klonopin and has no health coverage.
-The patient is given a script for Klonopin and written for DC.
-The patient has a seizure in the ER. ED Doc writes for Dilantin 800mg IV.
-The nurse gives a patient 8000mg of Dilantin instead of 800mg of Dilantin. The patient arrests and dies immediately thereafter.
-The nurse had to get THIRTY-TWO vials of Dilantin from 3 seperate Pyxis units.
-The nurse had to start a second IV to administer that much Dilantin.
-The ED doctor and the nurse are fired. The ED doc was fired for attempting to contact the deceased family.
-The ER doctor brings a wrongful termination suit against the hospital network, which triggers an investigation into the patient's death and a JCAHO investigation into the hospital's response to the death.
How did the nurse make that error? I am all for process errors, but that seems like the nurse egregiously circumvented the safeguards.
RN, BSN and others...
Jan 26, '07
Absolutely inexcusable. Also, think about how long it took to draw up 32 vials of med. It seems odd that no one else saw what she was doing and made an attempt to intervene.
Last edit by bill4745 on Jan 26, '07
: Reason: to add info