Wash. Woman Dies After Cleaning Fluid Injection

eak16 · Nov 27, 2004

These is nothing wrong with blaming systems error! Sometimes (often) it IS a systems error, that could have been completely prevented by instituting a different system. Blaming the system instead of the person just might spare them from PTSD. They have suffered enough, i'm sure.

stevierae · Nov 27, 2004

I work at this hospital, but not in this department.
Chad is right about what happened. Chlorexidine was put on the table near the end of the procedure to clean skin prior to skin closure and was accidentally drawn up and injected in the belief that it was dye.
No angel of death , no doctor vs nurse vs tech injecting issue... A horrible accident with horrible outcomes. Steps were taken that same day to make sure it could not happen again.
Everyone where I work feels awful for the patient, family, and all staff involved.

Funny thing is---back in the '80s, Chlorhexidine (scrub)came only as the brand name Hibiclens, (there was also a solution called Hibitane, which was discontinued) and was bright pink. When hospitals started trying to cut costs and buying generics, they all switched to CLEAR generic Chlorhexidine. Ironic that this penny-pinching measure at Virginia Mason will now likely cost them millions.

Still, no excuse. I am a firm believer in the 5 Rights of Medication Administration, as we were all taught in school, and there is absolutely no excuse in this day and age for having 2 identical clear liquids--one meant for injection and one for prep--in unlabelled containers side by side. But, of course, a "root cause analysis" of this sentinel event will be conducted, and "systems error--" NOT the individual who was downright negligent--will be blamed.

Why does it always take a death to promote change?

stevierae · Nov 27, 2004

These is nothing wrong with blaming systems error! Sometimes (often) it IS a systems error, that could have been completely prevented by instituting a different system. Blaming the system instead of the person just might spare them from PTSD. They have suffered enough, i'm sure.

Blaming the system instead of the person absolves the individual from accepting accountability for the action, learning from it, and being more careful in the future to not REPEAT the error or make a worse one. I think it's ludicrous to say "The vials looked similar" or "It was stored in the wrong drawer" as an excuse for giving, say, a fatal dose of IV push KCl when one MEANT to give IV push NS. What ever happened to reading labels? People need to learn to accept responsibility for their actions--not blame other people or "systems" for them.

PTSD--give me a break. This individual has caused a death that was absolutely unavoidable. How do you think the dead patient's family feels--do you really think they are concerned about PTSD on the part of the person that killed their mom, dad, husband, wife, or child? Do you really think they are comforted because a "root cause analysis" will be performed and, hopefully, prevent the problem from occurring AGAIN? It should not have occurred in the FIRST place!!

eak16 · Nov 27, 2004

Oh, i bet this person will be more careful than anyone else at the hospital when drawing up and giving contrast now, Stevie

stevierae · Nov 27, 2004

Oh, i bet this person will be more careful than anyone else at the hospital when drawing up and giving contrast now, Stevie

Oh, and I forgot--there need to be CONSEQUENCES for making errors as grave as this one. However, if one blames "systems error" why, then, the negligent party escapes accountability AND consequences.

eak16 · Nov 27, 2004

Oh, and I forgot--there need to be CONSEQUENCES for making errors as grave as this one. However, if one blames "systems error" why, then, the negligent party escapes accountability AND consequences.

wow- i wonder if something happened in your past to make you so sensitive about this isse. I continue to be content with learning from errors and forgiving.

Tweety, BSN, RN · Nov 27, 2004

But, you watch--I am betting that that is EXACTLY what wil happen.

If they are in the habit of not labeling similar containers, and have been doing it a while, then it is a systems error, especially if this was the way he/she was trained, in addition to a med error on the part of the injector.

But you watch--I am betting the institution blames it on unfortunate human error, rather than bear any of the responsibility themselves. This person is expendable, best not to ruin their reputation and loose money on profitable procedures.

I don't think the one who gave it should be let off the hook. But the system that lead up to the error needs some serious evaluating so it doesn't happen again. Blaming and frying the worker and leaving it at that isn't the best answer.

smk1, LPN · Nov 27, 2004

OMG-
I don't understand how this happened. Both the drug and the cleaning fluids were clear, but I don't think the body cleaning fluid would have been in any container accessable by needle.

not a nurse yet but this was my thought also... who would draw up cleaning fluid in a syringe? :uhoh21:

edited to say i just read chads theory and understand how it happened now but my goodness that whole scenario was just a recipe for disaster!

weetziebat · Nov 27, 2004

wow- i wonder if something happened in your past to make you so sensitive about this isse. I continue to be content with learning from errors and forgiving.

I think it is definately a systems error, and their way of doing things was an open invitation to disaster that should never have been started. And imagine many people thought to themselves that it wasn't safe but 'that's the way its done'.

And am certain the poor person actually responsible for giving the cleaning solution to the woman is devastated, and will certainly be super careful in the future. But they were responsible for a death, and it seems that just forgiving is not quite right either. Its a tough call.

Loribabble · Nov 27, 2004

Originally Posted by 3rdShiftGuy-

"But you watch--I am betting the institution blames it on unfortunate human error, rather than bear any of the responsibility themselves. This person is expendable, best not to ruin their reputation and loose money on profitable procedures. "

I live in Seattle and this has been all over the news here.... the from what I have seen, the hospital has taken full responsibility for this from the start and are considering it a systems error - I haven't heard much whether anything is going to happen to the employee...

Also - the last I heard was that the family was NOT going to sue... they were actually quite gracious considering the circimstances. They were upset, rightfully so.... but said that their mother was the type to forgive and move on and that is what she would have wanted them to do... so that is what they are doing.

To be honest... I have been really impressed at how this whole tragic situation has been handled.

It did freak me out as my dad has had several cardiac caths there.

I heard that my hospital does things the same way of having the chlorahexadine poured into unmarked sterile bowls to be drawn up... I am sure that has changed now.

CCU NRS · Nov 27, 2004

This is truly a sad case and I feel as others have stated it was completly avoidable, yes systems error but someone should have caught this eerror in procedure prior to it becoming this type of incident

stevierae · Nov 28, 2004

wow- i wonder if something happened in your past to make you so sensitive about this isse. i continue to be content with learning from errors and forgiving.

no--actually, i have written a couple of articles addressing medication errors and this whole trend--i see it every day as a legal nurse consultant--of blaming other people or systems for one's errors--often fatal ones.

here is one of the articles i have published. i have written another one addressing the new trend of citing "systems error" for anything that goes wrong as a way of avoiding personal responsibility. i will post it separately. you do not have to agree, but the opinions will certainly make you consider another viewpoint.

this is in response to the question asked in the march 2003 "vital signs:" "does your facility still view med errors as a "nurse's problem?"

just who else do you think should bear the blame when a nurse makes a med error?

when an individual makes a med error, he or she needs to accept the responsibility for that action, accept the consequences, learn from the mistake, (and allow others to learn from it) and move on. an incident report needs to be generated, as well as a sentinel event report, if indicated.

why should there be any need to shift the blame onto someone else?

giving meds these days is almost foolproof, given unit dose medication, access to the pharmacist who has all the information regarding any prescribed drug, including drug interactions, a vast array of drug handbooks for nurses, and the internet--not to mention the pdr!

i, frankly, am always amazed when i see nurses failing to double check their heparin and insulin dosages with another rn before administering them. i was taught that this was standard of care.

i am also amazed when people claim that they made a mistake because "the vials looked similar" (please!) or "someone put the wrong medication in the drawer," and the next person grabbed it, "assuming" it was what was supposed to be in the drawer. to me, that is inexcusable.

i, personally, know of an instance in which an rn gave pitressin instead of pitocin, iv, to a labor patient! the results were disastrous! and this was an ob nurse! what could have possibly caused her to make this error? her excuse was: "the meds were stored in alphabetical order, and i grabbed the wrong one."

don't people read labels, anymore, especially when drawing meds from a multi-dose vial?

don't nursing schools teach "the 5 rights of medication administration," or pharmaceutical math, anymore? i think they do. why, then, are there so many med errors?

consider this: when i was a navy hospital corpsman in the '70s, i worked on all the units. we had large multi-dose vials of stock medications on the floors. on p.m.s and nights, there was no in-house pharmacist.

when you wanted to give medication, you first calculated the dosage using your pharmaceutical math. if you were at all unsure, you conferred with another corpsman or two, or nurse or two, to check your math (and this was before calculators!) you also checked the pdr to familiarize yourself with that medication; reading up on normal dosage ranges, drug interactions, contraindications, etc.

i can remember having to dissolve morphine tablets in injectable ns to give injectable morphine, which required using pharmaceutical math.

i can remember having to use other types of insulin syringes to give regular insulin, which required using pharmaceutical math.

i can also remember having to calculate complicated pediatric drug dosages using clark's rule and young's rule, as our only stock of every drug was meant for adult patients.

we also very commonly had to split p.o. meds with a knife blade (no pill splitters existed back then) and mix our own iv piggyback meds (antibiotics, etc.)

no one made med errors. to do so would have earned one a captain's mast, not to mention potentially being "busted" to a lower rate (paygrade) and perhaps even dishonorable discharge. besides, we were well trained in complicated pharmaceutical math in corps school

when i went to nursing school in 1981, i was amazed at how the availability of a 24 hour in-house pharmacist and, particularly, the widespread use of unit dose medication made giving meds so easy.

still, even though i have been an rn for 25 years, i am not embarrassed to check my drug calculations with a colleague if i am uncertain as to their accuracy, and i still double check heparin and insulin with another nurse before giving it, as i was taught so long ago. if i am unfamiliar with a medication, i still look it up in the pdr.

please, fellow nurses, let's not get like the ever-increasing members of our society who are continually looking to "blame" someone else for their own actions. also, let's not use the lame excuse that "i was just too busy" to check, double check, and even triple check the effects of meds we are giving. a patient's life depends on it.