NOT nursing's fault in this med error

[NRSKarenRN, BSN, RN]

Medical error kills Hopkins cancer patient

A young cancer patient recovering at home from a bone marrow transplant has died after receiving an improperly mixed intravenous solution that apparently caused her heart to stop, Johns Hopkins Hospital officials say.

Baltimore Sun, Dec. 19, 2003

http://www.sunspot.net/news/health/bal-te.md.hopkins19dec19,0,5767345.story?coll=bal-home-headlines

After reading this article I surmise that a WHOLE shipment of TPN (usually 3-4 days for adults till stable at home) was improprrly mixed. Only way to prevent this is to test each batch of TPN. That wasn't being done when I last worked in Infusion 4 yrs ago. Anyone now if doable today??

Really question why pharmacy didn't prepare fresh solution per oders and send it out. I spent many late nights delivering (in 80's) changed enteral that pharmacist just prepared and grawing labs for TPN clients. Probably just faxed orders over WITHOUT nay verbal communication re rising K ---labs are always to be sent to pharmacy when known. I understand why some pharmacists are anal about this--prevents this type of mishap.

[imenid37]

The Sunday and Monday Sunpapers edition featured a story last week 12/14-15 on Josie King a child who died as a result of a series of medical errors 2 years ago. The story touted the pt. safety committe which Hopkins and the child's parents collaborated to form. (also see josieking.org). The Sun story (on Josie) mentioned how an agency nurse should been more aggressive in reporting the child's condition to her physicians. I wonder how many kids she was caring for and if she did report but did not document in such a way as to reflect the strength of what she was reporting to physicians. Both cases are extremely sad. As I understand, there is also a shortage of pharmacists. I don't know much about it, but I can only say I continue to see pharmacy making errors in sending wrong meds/ wrong dose even in the age of computerization. I think we often get the brunt of the blame for med errors as the bedside care-giver. Several years ago there was an error in mixing meds for the NICU at Arundel Medical Centre In Annapolis, MD and nurses were actually disciplined, though I think the med was mislabelled by the pharmacy. It is all very sad and hard for those who cared for these children, although of course, not as awful as it is for the parents, who, in both cases thought their very ill children were recovering.