Published Nov 20, 2000
This months survey question:
Have you ever been responsible for a medication error that caused harm to a patient?
Here are the results from this survey question with 1142 participants:
No 90.44 %
Yes 9.56 %
We encourage your comments and discussion on this question or even discuss how easily medication errors are missed. Have you ever had a close call or a last minute catch?
To post your comments, just click on the "Post Reply" button.
It's how nurses surf the web!
[This message has been edited by bshort (edited December 18, 2000).]
The kicker is "that caused harm to a patient" I had a near miss recently that almost made my heart stop. I'm an agency nurse and rely heavily on regular employees. I had an insulin injection for Mrs. "A". She was sitting at a table with three other women. I asked which patient was Mrs. "A" and one stated "I am" (no name bands, of course). The real Mrs. "A" sat quiet as a mouse who doesn't like shots. The CNA in the room realized what was happening and jumped to my rescue. She said these two women do this all the time. How nice if someone had reported this or made a note on the med sheet. I have a serious Guardian Angel. I still get the shivers.
Yes I have. Let me tell you about a serious close call that changed my nursing career. I had ten patients one night with a very inexperienced CNA ( I had only been a nurse for 4 months). I was SWAMPED without help. Anyway, I ended up taking a foley out of the wrong person and giving the wrong meds to the wrong patient. I was so busy, I didn't check his nameband and he answered to the name I called him (turns out he would have answered to anything). The good thing was, all I gave him was tylenol and a dulcolax suppository. The foley replacement was easy, and I learned one hell of a lesson. This is why I am so passionate when I post topics, because I could have very well lost my license as soon as I got it because I didn't have the good sense to DEMAND more help when I needed it. I also learned that in the busiest of times, that is when caution is of upmost importance. Thankfully, I have never had any other med error. I hope no one ever has to go through the anguish I feel when I think what I possibly could have done given the right mixture of meds.
There will be a new Institute of Medicine report coming out this spring. This is the same organization that put out a report last year of 98000 errors/deaths caused by medical mistakes in hospitals. This report hints to be even more scathing and I'm looking forward to it. The more the public knows what goes on in the hospitals, the better for the nursing plight. Here's an opinion from Modern Healthcare Mag....
November 13, 2000 Issue
Comin' at ya
Get ready for Medical Errors Part II. Healthcare executives who thought that last year's Institute of Medicine report on the dubious quality of hospital care was a one-shot shock are in for another rude awakening.
The upcoming sequel to last December's IOM blockbuster, which estimated that up to 98,000 hospitalized Americans die each year because of medical errors, is expected to blast the organizational practices of many hospitals.
This wholesale indictment of the treatment of hospital patients should touch off a firestorm of political attention and force providers to improve the processes in place at their institutions.
Despite the questionable assertions made in the first report, most hospital executives and trade associations took heed. But the momentum for action slowed as the healthcare spotlight focused on election campaigns, Medicare drug benefits, provider reimbursement and patient rights.
The new cast of characters in Washington is bound to home in on healthcare quality improvement. Watch for a flurry of headlines, fiery speeches and committee hearings designed to probe the inner workings of hospitals.
Stringent government regulation can be averted only if providers offer serious improvement plans. Hospital administrators can take the first step by correcting obvious organizational flaws in recordkeeping, order entry and transportation. Hospital managers should discuss shortcomings and solutions.
Providers also need to invest in products and services with a track record of improving efficiency and reducing medical errors. They also should support efforts by the Joint Commission on Accreditation of Healthcare Organizations and others to monitor and evaluate patient safety.
The focus on quality and error reduction must become an essential part of the healthcare business model.
I wrote a nice post under the original subject title, "Hit or near Miss" if anyone would like to read it. It is to long to post again.
Here is the post from Hit or Miss (entered by bshort):
This happened about two years ago after the hospital where I worked eliminated the pharmacist on the night shift. It is the night supervisor's job to fill the order from the pharmary. I took a verbal order for 30 mg. of a certain med. from a MD. I have a bad habit of writing my 3s to look like 8s because the loops are sort of tight. A secretary took the order off as 80mg., another RN thought it looked like 80 mg. and signed the order off. The supervisor brought down the whole bottle of the medication because nurses are not supposed to dispense medications and the instition gets around the "no nurse dispense rule" by saying that bringing the whole bottle down does not constitute dispensing meds. The only thing that saved us was the bottle contained 10 mg. tablets and the LPN who was supposed to actually give the med had never given 8 tablets before and thought it was a bit odd. She asked me about it, I just happened to be the nurse that wrote the 3 that looked like a 8 so the error was caught at the last second. Would the blame have mostly been mine cause I wrote the confusing dose, it sure would have and I acknowlege that. Is the system that allows so many people to handle an order before it gets to the person who actually gives the medication with out a pharmacist present set up to fail, I think so.
[This message has been edited by bshort (edited November 20, 2000).]
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