patient dies from combination of drugs that doc prescribed. who is responsible?

[premedwoahs]

is the nurse who administered, or the doctor who prescribed it responsible?

& why?

[cherrybreeze, ADN, RN]

I am not sure whether my inability to draw a clear answer regarding this query can be attributed to my lack of familiarity with the topic in question.

One thing I do know, what I'm reading here resembles the proverbial modern-day witch hunt.

The majority is blaming all individuals involved -- patient, nurse, pharmacist, and doctor -- and does so with such alarming finality without ever questioning whether the system failed.

I honestly believe such incident can be prevented if hospitals, for instance, can impose an effective means that will force personnel to do redundant checks concerning drug reactions.

In what way did the "system" fail...we ARE the system, and this is our JOB. It's not even "redundant checks" on drug interactions...you don't have to look up, say, valium, Percocet, and Ambien to know that they are all sedating, and to use a little discretion when administering. Witch hunt?? The system relies on the parties involved...MD, pharmacist, and nurse...to administer meds safely. There is no way to pass that on to someone else. That's what we're here for!

The case mentioned above where all the drugs were given at the same time...I think it's a bit different, and a bit more of the nurse's responsibility, when the meds are ordered PRN rather than all ordered scheduled. That is where our judgement becomes vital. If someone takes all of those meds together regularly at home, they can handle it. If not, then you'd want to stagger them.

[BabyLady, BSN, RN]

They weren't ordered to be given all at the same time. The Ativan was q8 hr for anxiety. The tylenol for pain, the serax to help sleep. the ordering MD assumed that the nurses would know not to give all at once!

The nurse giving it saw nothing wrong with what she did - she's known for "snowing" her pts so they "sleep".

The drugs were d/c the day after this incident to prevent a recurrance. Night nurse was NOT happy with us!

Pt survived. that's the main thing.

I was just using this as an example that it isn't always the MDs fault.

I have to disagree, yes, it is the nurses fault.

You have to pay attention whenever multiple drugs that are ordered and you might consider giving have the same effect....whether it's sedation, treatment for hypertension, etc.

I'm a first year RN...pharmacology is my weak point, and even that was obvious to me.

The nurse should be held liable for not asking either the MD or pharmacy.

Also, if this nurse has a reputation for "snowing" her patients, my question is why hasn't she been reported?

The MD d/c'd the meds not because they were prescribed in error, because he knows that at least one nurse wasn't administering the drugs for the purpose in which they were prescribed.

[~Mi Vida Loca~RN, ASN, RN]

I have to disagree, yes, it is the nurses fault.

You have to pay attention whenever multiple drugs that are ordered and you might consider giving have the same effect....whether it's sedation, treatment for hypertension, etc.

I'm a first year RN...pharmacology is my weak point, and even that was obvious to me.

The nurse should be held liable for not asking either the MD or pharmacy.

Also, if this nurse has a reputation for "snowing" her patients, my question is why hasn't she been reported?

The MD d/c'd the meds not because they were prescribed in error, because he knows that at least one nurse wasn't administering the drugs for the purpose in which they were prescribed.

I think that is what they said, they said it isn't always the Dr's fault and was implying it was the nurses fault and that the nurse had a habit of over medicating the patients to make them sleep.

[BabyLady, BSN, RN]

We were thought in nursing school that the one who gives the drugs carries all the responsibility. That means the nurse is responsible for this.

However, it is not that cut and dry.

I'll give you a good example.

In our unit, we give a lot of IV meds..bags of fluid for various treatments, etc.

My job: Is to check the order and send it to pharmacy.

Pharmacy's job: Is to mix the IV meds, put on a sticker, and send me back the bag.

My job again: Double check the sticker on the IV bag against the original order, verifying a match.

If it matches and is safe PER THE STICKER AND ORDER...hang the med.

However...we had a case where what was MIXED was a pharmacy error in our hospital a couple of years ago....where the saline concentration was too high in the bag.....but the order and sticker were correct.

No way can a nurse be held responsible for that...I can't look at a bag of clear fluid and tell if it's mixed correctly.

The Pharmacist was held liable...nurse was not.

It depends on the situation...you'll learn in school that situations for test-taking purposes vary greatly from what you run into in the hospital.

[Pepper The Cat, BSN, RN]

Also, if this nurse has a reputation for "snowing" her patients, my question is why hasn't she been reported?

Because the manager at the time said we couldn't "prove" anything. She was friends with this nurse. I made an incident report about another event, and this nurse was one of 3 involved. She called me at home and screamed at me for nearly 10 minutes before I hung up on her. I was so upset. When I talked to the manager about it, manager took HER side. Nothing was done. That nurse hasn't spoken to me directly since that incendent - and that was probably at least 5 years ago now. I will speak to her and she will respond, but she will not volunarily say anything to me.

[CuriousMe]

However, it is not that cut and dry.

I'll give you a good example.

In our unit, we give a lot of IV meds..bags of fluid for various treatments, etc.

My job: Is to check the order and send it to pharmacy.

Pharmacy's job: Is to mix the IV meds, put on a sticker, and send me back the bag.

My job again: Double check the sticker on the IV bag against the original order, verifying a match.

If it matches and is safe PER THE STICKER AND ORDER...hang the med.

However...we had a case where what was MIXED was a pharmacy error in our hospital a couple of years ago....where the saline concentration was too high in the bag.....but the order and sticker were correct.

No way can a nurse be held responsible for that...I can't look at a bag of clear fluid and tell if it's mixed correctly.

The Pharmacist was held liable...nurse was not.

It depends on the situation...you'll learn in school that situations for test-taking purposes vary greatly from what you run into in the hospital.

Well yeah, but the OP didn't ask if it was the nurses fault if the pharmacy mixed and labeled a med wrong.....but instead asked, who was responsible when a Doc prescribes a combination of drugs that ended in a patient's death? A different situation.

[cherrybreeze, ADN, RN]

Well yeah, but the OP didn't ask if it was the nurses fault if the pharmacy mixed and labeled a med wrong.....but instead asked, who was responsible when a Doc prescribes a combination of drugs that ended in a patient's death? A different situation.

That post was in response to someone saying that any med error is the nurses' fault, and was giving an example of why that's not possible. It wasn't a response directly about the OP.

[BabyLady, BSN, RN]

Well yeah, but the OP didn't ask if it was the nurses fault if the pharmacy mixed and labeled a med wrong.....but instead asked, who was responsible when a Doc prescribes a combination of drugs that ended in a patient's death? A different situation.

You are correct, but I wasn't responding to the OP, I was responding to the post I copied to my response.

[iPatch]

In what way did the "system" fail...we ARE the system, and this is our JOB. It's not even "redundant checks" on drug interactions...you don't have to look up, say, valium, Percocet, and Ambien to know that they are all sedating, and to use a little discretion when administering. Witch hunt?? The system relies on the parties involved...MD, pharmacist, and nurse...to administer meds safely. There is no way to pass that on to someone else. That's what we're here for!

The case mentioned above where all the drugs were given at the same time...I think it's a bit different, and a bit more of the nurse's responsibility, when the meds are ordered PRN rather than all ordered scheduled. That is where our judgement becomes vital. If someone takes all of those meds together regularly at home, they can handle it. If not, then you'd want to stagger them.

If you became agitated by my initial post, I would like to tell you it was not my intention.

I merely brought up the "system" since no one else did. Maybe it's because I haven't started nursing school yet, and my frame of mind is still different from the rest; but I don't think my opinion is improbable like you think it is.

That makes me feel inclined to address some of your comments.

When you say we are the system, that's like saying planet earth is the universe. I would like to think a system is an entity that is comprised of many interrelated parts. Organizational philosophy, company culture -- even the manner of reconciling patient records -- that's a part of an intricate system. They all blend to achieve a common goal.

It's more than just "we."

I also gave the example "redundant checks" as "imposed" by a system because such process forces a particular behavior that limits, if not eliminates opportunities for medical errors. We're blaming everyone, ignoring even the slightest possibility that perhaps, something rather than someone might have played a major role.

You asked me how a system can fail, and I would like to answer that with an example.

The pediatric dose of Heparin that nearly killed Dennis Quaid's newborn twins a few years back had the same size, shape, and color that could be easily confused with the adult dose. To me, the medical error is caused by several things: First, the health professional failed to double-check the lablels; second, although the manufacturer had prior awareness of such incident and began shipping Heparin with redesigned labels, it failed to recall the old stock already sitting in hospitals; and finally, the hospital where the newborns were admitted failed to foresee the possibility of such error occurring.

I think if the appearances were not confusing, the error might have been prevented. And as far as I know, the Quaids are not putting the blame on the health professional. Instead, they are fervently going after the drug manufacturer.

It seems they decided not to go after the "little people," which also addresses your bewilderment regarding my allusion to witch hunt.

On a final note, I'd like to point out that when you cited certain meds, claimed that "you don't have to look up" to know what they are (implying a confident level of familiarity), and said to "use a little discretion when administering," you were self-contradictory.

When a health professional starts to become complacent and chooses not to double-check a mundane task, simply because he or she is familiar, it opens up opportunities to make an error.

I think such decision constitutes lack of discretion.

[massrn116]

Had a patient for the first time in her admission, had been in for 5 days receiving vanco had a little renal insufficiency. I noted no vanco level was done. I find the docs let a lot slip by, I questioned, got the level, which was 44! Who was at fault? The MDs following every day or the RNs that may only have a patient a day or two?

[cherrybreeze, ADN, RN]

if you became agitated by my initial post, i would like to tell you it was not my intention.

no, not agitated.

i merely brought up the "system" since no one else did. maybe it's because i haven't started nursing school yet, and my frame of mind is still different from the rest; but i don't think my opinion is improbable like you think it is.

no one else used the words "the system," but they are discussing it. the pharmacists, the doctors, the nurses...are the system. if we are not, define it for me, please. what does your system consist of?

that makes me feel inclined to address some of your comments.

when you say we are the system, that's like saying planet earth is the universe. i would like to think a system is an entity that is comprised of many interrelated parts. organizational philosophy, company culture -- even the manner of reconciling patient records -- that's a part of an intricate system. they all blend to achieve a common goal.

actually, it's the opposite of saying "the planet earth is the universe." that would be saying that the responibility falls on to one, and i'm saying it does not. pharmacy is a part of it, nurses are a part of it, physicians are another part of it. so are hucs, so is the computer system we use to enter orders. however, it responsibility falls most heavily on those that prescribe, prepare, and administer. i'll ask again, what other specific people/units/variables are involved?

it's more than just "we."

you are narrowing my definition of "we," not me.

i also gave the example "redundant checks" as "imposed" by a system because such process forces a particular behavior that limits, if not eliminates opportunities for medical errors. we're blaming everyone, ignoring even the slightest possibility that perhaps, something rather than someone might have played a major role.

there are many different types of med errors. you should see the list to choose from, when filling out an incident report about a medication variation. errors from transcription, to preparation, to dispensing, there are a couple dozen choices. multiple checks are in place already. it's not something that you're going to fully comprehend when you're not doing it day in and day out, and have never seen it even. i am not sure what you mean by, "we are blaming everyone." not at all. but somewhere, despite the checks, things fail. who did depends on the specific error. if a medication that is prescribed, for example, that is not a proper dosage: the md who wrote is first at fault. s/he may have written the wrong dose. the huc entering the order may not question it, although if they have to type in an amount of 10 tablets to equate the written dose, that would be a red flag. if it's not questioned at that point, the pharmacy then gets the order. the pharmacist should question the dose. if they do not, they send up the med. lastly, the nurse receives the med, to give to the patient. s/he is pretty much that last stop on this trail, and at this point could (should) question the dosage. if s/he does not, the patient might even question it, when it's given to them. they may say, "i take 2 pills of this at a time at home, why am i getting 10?" however, most patients don't have a good understanding of their meds, so it may not happen then, either. for this type of med error to happen, every one of these checks has failed if the patient takes that med. but the checks are in place. this example is a totally different type of error than mentioned in the op, though. i think you get the idea.

you asked me how a system can fail, and i would like to answer that with an example.

the pediatric dose of heparin that nearly killed dennis quaid's newborn twins a few years back had the same size, shape, and color that could be easily confused with the adult dose. to me, the medical error is caused by several things: first, the health professional failed to double-check the lablels; second, although the manufacturer had prior awareness of such incident and began shipping heparin with redesigned labels, it failed to recall the old stock already sitting in hospitals; and finally, the hospital where the newborns were admitted failed to foresee the possibility of such error occurring.

i think if the appearances were not confusing, the error might have been prevented. and as far as i know, the quaids are not putting the blame on the health professional. instead, they are fervently going after the drug manufacturer.

again, this is a different type of error. the checks that you mentioned earlier, should have been done. in this case, yes, the manufacturer of the heparin should have made their labels more distinguishable. in this case, that is another part of the system, but in many errors, it would be irrelevant. in the example given of all sedating meds, this example is completely irrelevant. where i work, meds of different doses are kept in different places. things that look similar (saline and heparin flushes for iv's, for example, while one has a yellow label and cap and the other white) are put in separate drawers. vials of insulin that are floor stock (aspart and regular) are kept completely separate, too, so that one isn't grabbed on accident when it's next to the other one. but, like i said, in the errors mentioned in this thread, that's irrelevant. if a combination of 3 meds that can cause sedation are administered at the same time, resulting in an adverse event, it doesn't matter how they're labeled or where they're kept. you can't look the problem of med errors as a whole.

it seems they decided not to go after the "little people," which also addresses your bewilderment regarding my allusion to witch hunt.

if they decided not to go after the "little people," i am not understanding your comparison to a witch hunt. wouldn't that mean that they do go after "the little people?"

on a final note, i'd like to point out that when you cited certain meds, claimed that "you don't have to look up" to know what they are (implying a confident level of familiarity), and said to "use a little discretion when administering," you were self-contradictory.

"claimed?" that implies that you think i'm lying about that. believe it or not, there are meds that i give literally every day at work, some multiple times, so yes, i am very familiar with them and no, i do not need to look them up each and every time. (for example, toradol...i know that our guideline states to push it over at least 15 seconds. i know that i need to check their creatinine level prior to giving it, and that we shouldn't give it in patients with a history of renal problems, stomach ulcers, allergy to aspirin. i know that i may not give it if they are having low urine outputs post op, since we may not know if the cause of that is dehydration or renal insufficiency). although you imply otherwise, there is nothing wrong with that. to say that i "use a little discretion" when administering meds does not contradict that at all. discretion meaning, that if a physician has ordered iv ativan, morphine, and benadryl all prn, just because they're ordered doesn't mean they can or should all be given at the same time, it depends on a lot of factors. in fact, it's from having a knowledge of these medications that prompts knowing to use them with discretion. all of these meds have the potential to sedate the patient, and i know this. if i give them a dose of morphine, i am going to see how they react before giving another one. "discretion" when administering also means that, if a physician orders ativan 1-2mg iv every 2 hours as needed, i'm going to look at many factors: the other meds the patient receives, their vital signs, respiratory rate and quality, size/weight, and medication history when deciding if i should give 1 or 2 milligrams. that's my nursing judgement.

when a health professional starts to become complacent and chooses not to double-check a mundane task, simply because he or she is familiar, it opens up opportunities to make an error.

you assume complacency. knowing something doesn't mean complacency in any sense of the word. when you've looked up and given a med literally hundreds of times, you can know something. i know that iv ativan needs to be diluted at least equally with normal saline and pushed over at least 1 minute. i know that we give iv metoprolol at a rate no faster than 1mg/minute, and that we check a heartrate and blood pressure both before and 15 minutes after administration. i know that benadryl is pushed over at least 5 minutes. i know that on the floor, we can't give more than 5mg of morphine, 0.75mg of dilaudid, or 35mg of demerol in a single dose on a prn schedule. what i do always do is look up compatibililty with another med. if i am giving a med to someone with a pca, i always check to make sure the med i'm giving is compatible with the pca med. you seem to assume that my saying having knowledge of some med means i'm saying that i have knowledge of all meds, and that because i say there are things i don't have to check, that i don't check anything. that's both untrue, and unfair to assume. some meds, i can literally recite our guidelines word for word from the manual (see above). do i sometimes still check them anyway? you bet. that doesn't make me complacent.

i think such decision constitutes lack of discretion.

and that decision would be, what, exactly?

until you know what the job entails and actually do it, please don't make assumptions about those who do.

[manncer]

Phew! :argue: