Teen dies from Med Error in Labor

Published

The newspaper article (I will keep looking for the link for the article) said she accidently hooked up the epidural bag instead of the pennicillan bag for IVPB, she started seizing and died 2 hours later.

Apparently the pt. was very nervous about her epidural, the nurse took the epidural bag out of the pump and showed it to the patient. She apparently set the epidural bag right next to the IVPB bag of penicillan she was going to hang and got them confused.

The hospital uses a bar code system for meds, supposed to scan the med, nurses ID badge and the med before giving the med. Patient's ID band was not on the patient but still in the chart.

here's a TV link:

http://www.channel3000.com/editorials/9508296/detail.html

I feel bad for the family, but also feel terrible for the nurse who has been put on administrative leave. This could also impact the hospital's medicare standing as well.

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Sidebar: Do your hospitals have different tubing and pumps for your epidurals and do you label the bag differently?

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Specializes in MR Peds, geris, psych, DON,ADON,SSD.

not to mention the Director of Nursing and the Administrator of the hospital who is liable for the nurses mistake also.

one can never be too careful with reading the label 3 (three) times no matter what!!! oh yeah what ARE the 5 rights again?? right dose, right patient, right DRUG, right time, right route. Nursing 101!! i think this thread will probably get a lot of scrutiny.

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Specializes in Nurse Manager, Labor and Delivery.

Wow. Our epidural meds come in a 250cc bag....penicillin would be in a 100cc bag. I would find it hard to confuse those...but I am hoping they use different things in that institution.

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The director and administrators are not liable for the RNs mistake. Thsi is such a common fallacy in nursing. Nither are RN's legally responsible for the actions of an LPN or CNA.

not to mention the Director of Nursing and the Administrator of the hospital who is liable for the nurses mistake also.

one can never be too careful with reading the label 3 (three) times no matter what!!! oh yeah what ARE the 5 rights again?? right dose, right patient, right DRUG, right time, right route. Nursing 101!! i think this thread will probably get a lot of scrutiny.

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That's sad. On our unit, the nurses are unable to remove bags from epidural pumps-the CRNA's are the only ones with the keys.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

wow what ahorrible situation.

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Another link about the case. Federal officials issue "Immediate Jeopardy Warning"

http://www.channel3000.com/news/9558313/detail.html

RNs at our facility only do one thing with epidurals - turn the pump to stop on the order of the OB during pushing. That's it, I ain't touching it!!!!

Our epidurals are put on a syringe pump.

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The director and administrators are not liable for the RNs mistake. Thsi is such a common fallacy in nursing. Nither are RN's legally responsible for the actions of an LPN or CNA.

I don't know if I am 'legally' responsible for actions of LPNs and CNAs - but they do work under my license - I always assumed it was the same thing. If they screw up, it's on my license. Could someone explain the difference to me.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Check your State Nurse Practice Act regarding the roles of RN's and LPNs and especially, if you are in a charge nurse position and/or supervisory one. Good luck.

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We had the same thing happen a few months ago but we were fortunate that nothing horrible happened. I was so happy that I wasn't working that night. It went through 3 nurses and a CRNA before the night shift nurse found it. Of course it happened to one of our floor nurses daughter.

The nurse that was primarily responsible kicks herself for not listening to her gut. She watched the other nurse struggle to put it in the pump.. our PCN bags are 250cc and the epidural bags are 100.

Like said above it's back to nursing 101!! The 5 rights!

It was definetly a lessoned learned because I think we all are guilty of cutting corners now and then.

Also one time the pharmacy stocked epinephrine instead of ephedrine in our epidural box..luckily the nurse read the label!!

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Hi, everyone! I'm a pharmacist, as my username indicates, and have lurked on this board for quite a while. When I saw this thread, I decided to register and post.

Our epidural bags are 100ml, as are the antibiotic bags, but 90%-plus of our group B strep patients use ampicillin which comes in Add-Vantage bags, which certainly don't look like our epidural bags. Those who are penicillin-allergic get clindamycin, which is pre-packaged and doesn't look like an epidural bag either.

Not working on the floor, I'm quite naive about all the equipment, but reading this thread has me a bit worried!

Hats off to all of you - you have a TOUGH job!

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