Sentinel Event

  1. Has anyone heard anything about a sentinel event that occurred in a hospital here in Eastern North Carolina? Involved a medication error by a nurse--who was a new grad working in a peds ICU. Apparently a 6-year old boy died when his enteral tube feeding was attached by mistake into his CVL. Terrible . Was trying to find more information about it on the internet. Causing quite a shakedown in the hospital in which it occurred.
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    About VickyRN

    Joined: Mar '01; Posts: 12,037; Likes: 6,467
    Nurse Educator; from US
    Specialty: 16 year(s) of experience in Gerontological, cardiac, med-surg, peds


  3. by   CATHYW
    No, not a word. OMG, those poor parents. I feel badly for the nurse, too, but she should have CHECKED, if she wasn't sure!
  4. by   Rustyhammer
    I hate hearing about errors that cost the ultimate!
    We hear about them from time to time and are reminded that it could happen to us too.
    We all need to remember to be careful out there!
  5. by   MPHkatie
    That nurse must have worked very very very hard to get the feeding tube connected to the CVP. Because of errors years ago (In the 1970's) the companies have made the tubing almost totally incompatible- so that when you are trying to do such a thing, you get an idea that it isn't supposed to go this way. She would have almost had to have rigged the thing, depending on what the hospital was using.
  6. by   MPHkatie
    that last sentance should say, dependeing ont he equipment the hospital was using.... ha ha sorry. I'm sorry, but that is a totally avoidable thing and it frustrates me that it still happened.
  7. by   VickyRN
    The DAY AFTER the event occurred, the hospital had people FLOWN IN to examine their whole system. The old enteral pumps were removed in one day (HUGE hospital) and new, smaller kangaroo pumps (with tubing entirely incompatible with IV's) installed.
  8. by   TaraER-RN
    wow...that is scary...thats why I still doublecheck things that don't seem right, its been a year since I was the "new grad" but I'm still a newbie and am lucky that the minor errors I have done have not cost life or injury...unfortunately we have to learn from our mistakes...but when someones life is taken its pretty hard to justify that. I feel awful for the patient and their family and that nurse...she will have to live with that the rest of her life!