What would you do if you an RN, go to an emergency room with anaphylaxis. ED doc orders epic 0.3 mg IM, and the ED RN gives you the same amount of epic 0.3 mg IV......
of course your BP goes from 170/110 to 70/30... now you need fluids (5-7 bags), Troponin goes to 4.6, chest pain is severe, EKG shows lots and lots of PVCs, HR is 120-137 sustained for the next 7-8 hours. Cardiologist is called, now you have an echo, a stress test, a CT of chest, D-dimer is a bit elevated 518... Of course you are now admitted into this hospital for 3 days until luckily your heart is cleared.... When you finally feel more alert 4 hours later after the incident you ask, the nurse at this observation unit, Who gave the order for IV epi?
the attending NP comes in an says: you deserve to know there was a medication error...
You knew it all long but wondered why no one said a thing.... now you feel quite traumatized after feeling that Gigant Mule of EPI that kicked your chest. Your heart felt as if was going to explode together with your brain and head. You were stucked in a treadmill exercising for hours while you were lying in ahopsital bed sweating profusely and asking for ice packs and fans trough your stay....
Any ideas?
By the way, they say because you aren't death there is no case, and because you are young and sustain "no physical damage" there is no case...; but what about the emotional distress and having to be off work for 10 days after while your heart rate went back to normal... and the nightmares, feelings you were going to code....
for anyone to take your case you have to prove permanent harm came to you and that another nurse in the same situation wouldn't have made that mistake. Also, attorneys turn down winnable cases all the time because there isn't enough money in it for them. After fees, etc. a case like this wouldn't leave you with anything left.
I may not have a case, nor I am seeking any compensation. However, as a nurse I have the duty to report and let the public know, plus ensure that this situation is dealt with an appropriately. I had done just that and I have finally gotten some answers to include having a risk manager involved. I do not want this to happen to anyone else, specially if can be avoided. I have learned now what happened (won't go into details), but my win here is not $$$ it's to know that a situation like this has not been overlooked and treated as another mistake, because you know: "to err is human"... Mistakes are made daily, is what we do about them and what we learn what matters!
As an RN I would probably try to find some compassion for the fact that another RN made a mistake. I realize you have had a traumatic experience but it is important to remember that it was a mistake and that the RN involved is probably also incredibly upset with herself.
Obviously I would not be paying for the hospital bill. I would be calling the patient advocate to make that very clear.
Compassion is there. Because I care about that RN, I want he/she to work in a place where there are enough safeguards and education in place that will help nurses to avoid making some of those mistakes. He/she could have killed me or anyone else. I have said to management clearly: "I know without a doubt that nurse did NOT mean to harm me".... But again, we all have to learn from our mistakes. It happened to be that this was an RN and I am another, but regardless of who made the mistake we all have to be educated. I don't know if you read on my post or if I mentioned that: The RN during my stay in the hospital never acknowledge the mistake, neither the ED mentioned it happened! I put it together 4 hours later when I found myself in some sort of observation unit being ready to be admitted. As a nurse I was taught to always acknowledge my mistake and even say sorry if needed to. I get it, we all make mistake, but it's what we do it with it, how we handle the situation.
I didn't get an explanation or a clear answer until 11 days later after much asking to speak with the ED manager. It made me wonder, is that how that facility handle those type of situations? The statement was: "She is being admitted to monitor her heart rate. Never in the ED was mentioned that there was a medication error. So just hypothetically speaking, had I died, what information would my husband had gotten? Patient die due to anaphylactic shock? or would have they disclosed the medication error?
That I do not know, but after not being briefed on what happened on a timely manner and finally being told several hours later... what would you think?
Just remember, I was the patient. I was confused as heck... I couldn't even think straight what happened until later on during the day, all I know something wasn't right. I may have even blacked out and not even know. I can't fully remember. Although, I remember vividly how I felt when than EPI went in, it was the most horrifying feeling of my entire life, feeling that my heart was ripping into pieces while my brain was also doing the same, immediately after the most severe chest pain I have ever experienced began... And again that was just what I felt....
The RN during my stay in the hospital never acknowledge the mistake,
It is very, very likely she was instructed not to. As an RN you should know this. Anytime an event like this happens attending physicians, administration and risk management are the ones who talk to the patient.
The RN during my stay in the hospital never acknowledge the mistake, neither the ED mentioned it happened! I put it together 4 hours later when I found myself in some sort of observation unit being ready to be admitted. As a nurse I was taught to always acknowledge my mistake and even say sorry if needed to.
1 hour ago, Wuzzie said:
It is very, very likely she was instructed not to. As an RN you should know this. Anytime an event like this happens attending physicians, administration and risk management are the ones who talk to the patient.
OP, I would not have expected the RN to speak with you about this while you were in the ED; today's climate is not supportive of that action.
However, at least at the point that a patient is going to be presented for obs/admission because of what happened, someone needs to talk. For reasons not even related to the concept of apology, the hospital should have a duty to disclose what's going on and why in a time frame that benefits the patient's real-time decision-making whenever remotely possible.
1 hour ago, winkiebob said:
I didn't get an explanation or a clear answer until 11 days later after much asking to speak with the ED manager. It made me wonder, is that how that facility handle those type of situations? The statement was: "She is being admitted to monitor her heart rate.
Reasons and excuses and current climates aside, this is the very kind of thing that makes people furious. As it should. There is no excuse for being able to get away with not leveling with someone until after it's too late for them (or their supports/agents) to have any real-time input into the matter.
No one could possibly benefit from this behavior except the party/parties responsible for the mistake, and sometimes it's pretty astounding what kinds of things can happen when places are allowed to take the most circuitous and disingenuous path possible towards officially acknowledging error. Sometimes it benefits the responsible parties a great deal.
No one could possibly benefit from this behavior except the party/parties responsible for the mistake, and sometimes it's pretty astounding what kinds of things can happen when places are allowed to take the most circuitous and disingenuous path possible towards officially acknowledging error. Sometimes it benefits the responsible parties a great deal.
Which is exactly why they do this. Healthcare corporations pay lip-service to the public about how they "care" about their patients when everybody and their brother knows that first and foremost they care about their bottom line and will do whatever they need to do to protect it. Patient care be damned.
She stated she was hospitalized and out of work for a week, so of course there is financial consequence. She should be made whole.
Actually, ended up being out of work for a month. Even though heart shows no sign of damage. Taking a betablocker to keep HR down and also having insomnia and waking up having nightmares not able to sleep, prompted GP to give 0.5 alprazolan daily for 10 days; which reported back to work... not allowed to work until fully cleared all meds related.
OP, I would not have expected the RN to speak with you about this while you were in the ED; today's climate is not supportive of that action.
However, at least at the point that a patient is going to be presented for obs/admission because of what happened, someone needs to talk. For reasons not even related to the concept of apology, the hospital should have a duty to disclose what's going on and why in a time frame that benefits the patient's real-time decision-making whenever remotely possible.
Reasons and excuses and current climates aside, this is the very kind of thing that makes people furious. As it should. There is no excuse for being able to get away with not leveling with someone until after it's too late for them (or their supports/agents) to have any real-time input into the matter.
No one could possibly benefit from this behavior except the party/parties responsible for the mistake, and sometimes it's pretty astounding what kinds of things can happen when places are allowed to take the most circuitous and disingenuous path possible towards officially acknowledging error. Sometimes it benefits the responsible parties a great deal.
The ED physician came to me while I was in the ED and stated “you will probably need to be admitted for observation at least for 4 to 6 hours to keep an eye on your heart rate”... never she said why my HR was elevated. I remember still being confused at the time. But there was no acknowledgement of a medication error at the time. Neither my husband was told what had happened, just that I needed to be admitted for my heart rate to be monitored.
The anesthesia literature for YEARS has supposed the concept of reporting your error to the patient with apologies and let them know what strategies will be utilized so that it doesn't happen again. Patients are supposedly, less likely to sue the practitioner with this approach. However, I think the OP deserves some compensation for this since this was such an egregious error; OP could have easily had permanent sequelae from this. I know I would feel less likely to sue if 1. They just offer a settlement, 2. Be empathetic for the trauma they caused me and 3. Explain what steps they are taking so this doesn't happen to anyone else.
rvzohfeld, BSN, MSN, RN
34 Posts
I may not have a case, nor I am seeking any compensation. However, as a nurse I have the duty to report and let the public know, plus ensure that this situation is dealt with an appropriately. I had done just that and I have finally gotten some answers to include having a risk manager involved. I do not want this to happen to anyone else, specially if can be avoided. I have learned now what happened (won't go into details), but my win here is not $$$ it's to know that a situation like this has not been overlooked and treated as another mistake, because you know: "to err is human"... Mistakes are made daily, is what we do about them and what we learn what matters!