A sobering story-------

cindy_rn456 · Nov 29, 2015

Did you do anything to prevent or report these alleged errors? Call out the nurse doing it, repot to the charge or manager, use a pt safety line? If not, why? Imho, if you did not, you are complicit I the errors AND a huge part of the cult of silence that enables med errors to go unaddressed.

How could I prevent it when they weren't my patients? I reported it to the supervisor and DON who said they would 'handle it'. The nurse came back to work the next day (no suspension, ramifications, better yet he remained the charge nurse to this day). Needless to say I put in my two weeks and hauled ass out of there.

Horseshoe, BSN, RN · Nov 29, 2015

I
Susie2310, I don't see how you've assumed that from my posts (when I've said that at my place of employment, I've witnessed seasoned nurses kill 3 patients in one night due to insulin overdoses for patients who weren't even diabetic!!! And were NOT reported!!!)

How could I prevent it when they weren't my patients? I reported it to the supervisor and DON who said they would 'handle it'. The nurse came back to work the next day (no suspension, ramifications, better yet he remained the charge nurse to this day). Needless to say I put in my two weeks and hauled ass out of there.

Nothing was done after the first non diabetic patient given an insulin dose died? And then a second non diabetic patient subsequently died of another insulin OD? Why didn't someone call the police? What do you mean, it wasn't your patient?! And because no one acted, a THIRD non diabetic patient was sacrificed to that psychopath?! Why wouldn't you have taken this all the way up the chain, to law enforcement, to the BON, to anyone who would listen?!?!? You really just left and said nothing more about a nurse who would willfully give insulin overdoses to patients who were not even diabetic?

cindy_rn456 · Nov 29, 2015

Nothing was done after the first non diabetic patient given an insulin dose died? And then a second non diabetic patient subsequently died of another insulin OD? Why didn't someone call the police? What do you mean, it wasn't your patient?! And because no one acted, a THIRD non diabetic patient was sacrificed to that psychopath?! Why wouldn't you have taken this all the way up the chain, to law enforcement, to the BON, to anyone who would listen?!?!? You really just left and said nothing more about a nurse who would willfully give insulin overdoses to patients who were not even diabetic?

First, I'm not on trial here and administration, and DOH was informed. And I trusted that when my superiors said they would 'handle it' that they would.

secondly,

Correction: One of the patients died directly as a result of the insulin overdose, the other two coded at the same time but were revived.

Thirdly, I left because there were other scary things going there that I didn't want to be a part of. That facility had already developed a 'cult of silence' and because I expressed that I wouldnt be a part of that they treated me poorly.

MassED, BSN, RN · Nov 29, 2015

I read the article. It is a sobering story, but I'm not sure what conclusions I am supposed to draw from it (it's also kind of weird to read the v. serious, rather melodramatic article, and then the little blurb at the bottom from the author about she has "restless feet" and is always on the hunt for the best cheesecake ...) The article makes the usual argument about how healthcare should be more forgiving of nurses' errors and not stigmatize nurses for making them, but the nurse featured in the article accidentally gave 10 times the ordered dose of a serious medication to a critically ill small child who died a few days later. I'm sorry that the nurse involved eventually chose to commit suicide, but, at the same time, how much forgiveness can the system afford? How much of a margin of error is acceptable? People who are sick and vulnerable are counting on all of us to get things right. I wonder how the author of the article would feel if it were her child who had received the overdose.

I wonder about her own practice, after 25 years, did she not check meds with another nurse, as is common place? Especially a medication that if unchecked, could irreversibly harm a patient? Maybe this facility, like where I work, will implement a system that requires med scanning and pharmacy oversight, so that a nurse isn't accountable or responsible directly for drawing up meds. I may hate scanning, but the medication safety piece has saved me, as it has others. This is a learning moment. Regarding Kim's mental health, as well as nursing and patient safety, medication safety, and the importance of the facility to implement checkpoints and provide remediation and mental health support. It is sad, unfortunate, and who knows if any of the methods had been implemented if it could have saved her from her own obvious hatred of herself for her actions. I feel bad for her, as you know she did not mean any harm. It is so very sad.

elkpark · Nov 29, 2015

What you are saying is true, the safeguards need to be followed, but again I feel these med errors could have been prevented simply by better hospital med policies. Why would an NICU need adult heparin vials and keep them in the ADU alongside infant doses? This makes no sense to me! This was how the med error involving the Quaid kids happened, an adult vial was grabbed by mistake. On top of this the vials were labeled similarly which lead Dennis Quaid to file a lawsuit against the pharmaceutical company.
The other errors would not have occurred if single use prefilled syringes or volutrols with the appropriate dose were in the ADU. There is no sane reason to have a calcium chloride vial that contained over ten times the expected dose! The teen mom that died in Madison got an overdose I believe because the nurse drew up the wrong amount. You are right that she didn't follow policy and skipped the barcoding process that hopefully would have prevented the error. She also had done back to back shifts with little sleep I believe a 16 hr shift the day before and then made the error the next morning. Criminal charges were even filed against her!
All that aside if only the correct dose was available in the ADU this wouldn't have happened. You haven't made a case to me to explain why this shouldn't be standard practice in all hospital systems.

I don't disagree with you about safety systems and doing everything possible to minimize the opportunities for errors. Of course that should be an ongoing process. However, it sound like you're saying the nurse bears no responsibility for having administered the overdose. Yes, it's a good idea to not have vials that look alike but have different contents, etc., etc., but what is stopping the RN from being careful? In my experience, and, I would guess, the experience of most people here, a big overdose looks wrong right away -- an unusually large number of tablets, or an unusually large amount of fluid in the syringe once it's drawn up -- which should be a flag to any reasonably prudent nurse that this doesn't seem right and maybe I should check again. Would this have happened if the nurse had checked "the 5 Rights" when drawing up the medication and before administering the medication, the way everyone is taught we should? There is no "system" that is so safe that nurses don't need to be alert and careful in administering meds. I understand the pressure to get a lot done in a short time; I work in an acute care setting (I'm not practicing bedside nursing, but I work all day with nurses who are), and I know that everyone has her/his own comfort level with what shortcuts and "corner-cutting" s/he is willing to take. And, yes, pharmacy and other department personnel also make errors. But the nurse administering the medication is the "last line of defense" in medication safety. It's our obligation and responsibility to be prudent and safe in our own practice, regardless of what safety systems may or may not be in place, and what errors other personnel may have made. I'm not saying they shouldn't also be held responsible, but, unless something is just mislabeled, I don't think that excuses the nurse. I don't see it in my current workplace, but, in the last hospital in which I worked (and I was doing bedside nursing, and administering medications, every day), I saw other RNs routinely bypass the safety checks built into the hospital's medication administration system for convenience, and this was not just allowed, but actually encouraged by a few of the unit nurse managers. (This was my first experience with a computerized/barcode med administration system, and the thing I really liked about it was that, if you just followed the process the way it was supposed to work, it made it virtually impossible to make a med error. I'm sure that the Washington hospital has a similar system.)

There's no safety system that can protect clients if nurses aren't following the established procedures and processes and, IMO, it's a big mistake to put too much faith in those kinds of systems.

And I'm not at all saying that I think the response to errors should be punitive; I'm a big believer in the "just culture," "let's all work together to fix the problems" kind of approach. But, to me, part of that is holding people accountable for things like bypassing protections that are built into the system and basic expectations of practice.

Esme12, ASN, BSN, RN · Nov 29, 2015

This has been discussed in length at the time of the incident. This nurse who had worked 25 years caring for critically ill infants made one mistake and lost everything because the "corrective action" is always the nurse.

https://allnurses.com/nicu-nursing-neonatal/sad-story-for-584375.html

https://allnurses.com/washington-nursing/suicide-of-rn-555775.html

https://allnurses.com/general-nursing-discussion/nursing-error-675476-page2.html

Anna Flaxis, BSN, RN · Nov 29, 2015

The order was for 140mg. The drug is supplied in 1gm/10mL vials. The ordered amount would have been 1.4mL. The amount given was 1.4gm, or 14mL. The nurse would have had to open 2 vials to draw up this amount, and would have had to use a 12mL syringe. This would be a big cue to someone experienced in giving CaCl to infants/peds.

At the bedside, a second review of the order should have been done. If barcode scanning is not in use at this facility, then following the 5 rights with the MAR at the bedside should have prompted the nurse to realize the dose was wrong. If barcode scanning is used, then because this would have been a partial package, the nurse would have seen a pop-up that she would have had to acknowledge prior to proceeding, and she would have been prompted to manually enter the dose.

It is difficult for me to imagine how someone so experienced could have made this particular mistake, but it sounds to me like she confused 1.4mL with 1.4gm, and it slipped past all the safety checks along the way.

And yet, I do think that the stipulations placed on her license were harsh. Nobody is going to hire a nurse with those kinds of stipulations. Her career was essentially over. Clearly, she was so wracked with guilt that in end, she chose to take her own life. This should not have happened, and may not have, had the incident been handled differently.

Placing her in a non-clinical role during the course of the investigation and requiring her to use the EAP and attend counseling sessions regularly would have been reasonable, and once the systems flaws that allowed this to happen were identified, involving her in the systems improvement process while putting her back in the clinical area with appropriate support, might have had an entirely different outcome.

Nurse Leigh · Nov 29, 2015

Clinician Support: Five Years of Lessons Learned

Found this regarding a hospital system's support system for those who have made a medical error.

OCNRN63, RN · Nov 29, 2015

Deleted.

brandy1017, ASN, RN · Nov 29, 2015

I agree. This article is much better written. I couldn't read the one at the beginning of this thread either.

The bottom line the hospital recognized this error was also a system error and finally changed the dispensing of the med to make it safer. It's just too bad they hadn't done that in the first place then the baby and the nurse would probably still be alive! Unfortunately it seems to take a med error and the nurse being hung out to dry before safer systems are installed!

Horseshoe, BSN, RN · Nov 29, 2015

I don't disagree with you about safety systems and doing everything possible to minimize the opportunities for errors. Of course that should be an ongoing process. However, it sound like you're saying the nurse bears no responsibility for having administered the overdose. Yes, it's a good idea to not have vials that look alike but have different contents, etc., etc., but what is stopping the RN from being careful? In my experience, and, I would guess, the experience of most people here, a big overdose looks wrong right away -- an unusually large number of tablets, or an unusually large amount of fluid in the syringe once it's drawn up -- which should be a flag to any reasonably prudent nurse that this doesn't seem right and maybe I should check again. Would this have happened if the nurse had checked "the 5 Rights" when drawing up the medication and before administering the medication, the way everyone is taught we should? There is no "system" that is so safe that nurses don't need to be alert and careful in administering meds. I understand the pressure to get a lot done in a short time; I work in an acute care setting (I'm not practicing bedside nursing, but I work all day with nurses who are), and I know that everyone has her/his own comfort level with what shortcuts and "corner-cutting" s/he is willing to take. And, yes, pharmacy and other department personnel also make errors. But the nurse administering the medication is the "last line of defense" in medication safety. It's our obligation and responsibility to be prudent and safe in our own practice, regardless of what safety systems may or may not be in place, and what errors other personnel may have made. I'm not saying they shouldn't also be held responsible, but, unless something is just mislabeled, I don't think that excuses the nurse. I don't see it in my current workplace, but, in the last hospital in which I worked (and I was doing bedside nursing, and administering medications, every day), I saw other RNs routinely bypass the safety checks built into the hospital's medication administration system for convenience, and this was not just allowed, but actually encouraged by a few of the unit nurse managers. (This was my first experience with a computerized/barcode med administration system, and the thing I really liked about it was that, if you just followed the process the way it was supposed to work, it made it virtually impossible to make a med error. I'm sure that the Washington hospital has a similar system.)
There's no safety system that can protect clients if nurses aren't following the established procedures and processes and, IMO, it's a big mistake to put too much faith in those kinds of systems.
And I'm not at all saying that I think the response to errors should be punitive; I'm a big believer in the "just culture," "let's all work together to fix the problems" kind of approach. But, to me, part of that is holding people accountable for things like bypassing protections that are built into the system and basic expectations of practice.

WELL SAID!!!

Would you want your pilot to rely solely on the autopilot functions and not be able to fly the plane if all those systems failed? I think not. The nurse truly is the LAST point where the mistake will either be caught or the mistake will be made. It's a huge responsibility, but one we take on when we accept an assignment. No amount of system controls will make a med error entirely preventable, which is why a nurse's eyes and brain must be completely engaged when administering meds to a vulnerable person.

Horseshoe, BSN, RN · Nov 29, 2015

The order was for 140mg. The drug is supplied in 1gm/10mL vials. The ordered amount would have been 1.4mL. The amount given was 1.4gm, or 14mL. The nurse would have had to open 2 vials to draw up this amount, and would have had to use a 12mL syringe. This would be a big cue to someone experienced in giving CaCl to infants/peds.

Is this really the case? I'm beyond baffled how this happened.

Placing her in a non-clinical role during the course of the investigation and requiring her to use the EAP and attend counseling sessions regularly would have been reasonable, and once the systems flaws that allowed this to happen were identified, involving her in the systems improvement process while putting her back in the clinical area with appropriate support, might have had an entirely different outcome.

Yes, I think that would have been a far better way to handle it, instead of "escorting her out of the building," promptly firing her, and reporting her to the BON. Accountability, yet not cutting off her nursing legs.