LOS ANGELES (Reuters) - A 69-year-old woman who was accidentally injected with a toxic cleaning fluid as she was prepared for surgery at a Seattle area medical center has died as a result, hospital officials said on Wednesday.
Doctors had worked intensively to save the woman since she was mistakenly injected with the solution on Nov. 4, a spokeswoman for Virginia Mason Medical Center said, but were unable to save her.
McClinton was supposed to be injected with a contrast dye to assist in a radiology procedure, but instead was accidentally given a cleansing fluid typically used to prepare the exterior of the body for surgery. Both are clear liquids. The spokeswoman said policies at the hospital had been changed so that the cleansing solution would not be mistaken for the dye again.
::snip::
McClinton was supposed to be injected with a contrast dye to assist in a radiology procedure, but instead was accidentally given a cleansing fluid typically used to prepare the exterior of the body for surgery. Both are clear liquids. The spokeswoman said policies at the hospital had been changed so that the cleansing solution would not be mistaken for the dye again.
Frankly, I would be a little scared to go to a facility where there were "never any med errors".
There is a reason not to be punitive with errors and to look at the system-- we want to make sure that workers report their errors so corrections can be made as soon as possible.
You know, truthfully--NS is NS. I can't imagine that there WOULD be any untoward effects, even if the NS was not specifically manufactured and labelled for IV use, and particularly if she only got 1 liter. It probably did not have all the preservatives that some IV NS has, but, then, there are times that you don't necessarily want all those preservatives, either, and specifically request preservative free injectable NS from the pharmacy. I mean, at least SOME portion of the pourable or bagged NS--for irrigation--that we use in surgery is absorbed into the systemic circulation--and, particularly in laparoscopic surgery, we use liter after LITER of NS for irrigation in an open belly. We irrigate grafts meant for implant--including cardiac grafts--with NS for irrigation (NOT IV NS) and we often mix NS for irrigation with contrast to do a cholangiogram. Even though distilled H2O--for irrigation--is labelled "For irrigation ONLY" (and for that matter says, "Unlawful to dispense without a doctor's prescription"--WATER, mind you!) it is still perfectly drinkable.
I really appreciate your response. We never figured out if this was just a lucky outcome that there was no harm to the patient. Even the MD did not have an answer when we reported it. Thanks
Ask yourself, "If this were my mom--would I sue?" My mom is no longer living--but, if it had been my mom, you bet I would. Not out of greed, but to hopefully make a point, out of principle, and prevent it from ever happening to anyone else. It would be different if the situation was unavoidable, or if it didn't result in death--but that's not the case here.
I will answer honestly by saying I don't know if I would sue or not. I would hope that if it were truly an accident and I was certain and/or could see that the story they were telling me was the truth I would not. The media coverage of this story to some extent reveals that they could not keep a lid on it completely. The other side of that is I am human and with my human nature I would likely see $$$$ and feel that any facility of this size has insuance and could afford to pay me for their mistakes.
I feel that my Mother is also a kind loving person that would forgive and move on if it were truly an acident. I however am a person with bills and debt. Just how often am I going to get a chance for a payday like this? I would probably go for the $$$$ unfortunately that is what it comes down to. Would any amount of money ever brig my Mother back? NO! Would I miss her less while spending my money? I guess I would have to find out!
LOL, Tweetie, I am not THAT ancient--I am 50--but, I can only speak for the military hospitals where I worked, and I was in the Navy for 6 years. As I stated, we were all very well trained in pharmaceutical math; we checked our calculations with other corpsmen or RNs before dispensing; we read labels and talked with our patients (and these were loooong wards, ORs and emergency rooms) and we knew that anything we did wrong would result in disgrace, the end of military service via dishonorable discharge, and almost certain inability to find a job on the outside because of it. When we came on shift, whoever was dispensing meds that day had a responsibility to go through each and every one of the med cards--hanging on a hook board, by times--and check them for changes, updates, etc. as well as ensuring that they were delivered on TIME.
I remember one occasion--this was in Newport, R.I. somewhere between '73-'75--where the wind from the open window directly across the room blew one of the med cards off a hook and under some surface--or, maybe it was dropped there when the med corpsman was checking the med cards at the beginning of the shift. As a result, a patient did not get her 2 a.m. IM antibiotic. When it was found, luckily in time for the 6 a.m dose (we had to wash the floors in those days, so it was located while cleaning up the nurses' station) the med corpsman duly reported it to the charge nurse, who called the night supervisor, who wrote up a detailed incident report and passed the information on to the ward supervisor when she came in in the a.m. It was a huge, huge deal and the corpsman went to captain's mast and was busted one paygrade. She was removed from direct patient care and placed in an administrative position. It was the scandal of the hospital. In the entire time I was there, that's the only med error I ever heard about.
Doesn't this negate your statement, "no one made med errors"?
I will answer honestly by saying I don't know if I would sue or not. I would hope that if it were truly an accident and I was certain and/or could see that the story they were telling me was the truth I would not. The media coverage of this story to some extent reveals that they could not keep a lid on it completely. The other side of that is I am human and with my human nature I would likely see $$ and feel that any facility of this size has insuance and could afford to pay me for their mistakes.
I feel that my Mother is also a kind loving person that would forgive and move on if it were truly an acident. I however am a person with bills and debt. Just how often am I going to get a chance for a payday like this? I would probably go for the $$ unfortunately that is what it comes down to. Would any amount of money ever brig my Mother back? NO! Would I miss her less while spending my money? I guess I would have to find out!
A family member of mine actually did die from a medication error years ago. It kept me from being a nurse for many years. We didn't sue, but I think now that we should have. How can money make up for that loss? It can't. I would have given all the money in the world to be able to pick up the phone and talk to her, or go shopping, or make play dates for our children. Put a price tag on that--the missed holidays, the sharing, the just being-there-for-you relationship that we had.
Yes, we should've sued. Who knows if the problem that caused her death was ever resolved? Who knows if the system changed or how many other people died from the same fatal combination of medications?
We don't know now and didn't then, but I'm very sure that had we sued, something would've changed. I just hope that others didn't die from this same error.
Stevierae, there is no "escape" from the personal responsibility of committing a med error, and I doubt that health care personnel can. But the "systems error" approach was put into effect for a reason, and it was a very good one.
Everyone makes mistakes. Everyone. Even you. When you make a statement like you did, that you never made a med error, I not only don't believe it, I have to wonder how many errors you made that simply weren't caught.
If the same type of error is made by numerous personnel, then it behooves the hospitals to dig deeper for the reasons that this type of "accident" keeps happening. It behooves the hospitals to share some responsibility and change what can be changed to prevent others from needless death and disfigurement from this type of error.
Because we used "system error," we were able to more accurately track errors, and we have significant changes to the way we do things. You may talk all you want about the painstaking calculations and unlabelled vials that you used, but the fact remains--none of that was safe. We now can no longer write "U" for "Units," or MSO4 for "Morphine" when taking orders, for instance.
While I respect your opinion, Stevierae, I have to assume that you haven't been a floor nurse for a few years to have said some of the things that you did. I disagree that mandatory overtime, exhaustion, and understaffing play no part in the commission of med errors.
But we're all entitled to our opinions. This is mine.
Well put, Angie. Everyone does make errors and there is absolutely no reason to continue unsafe practices such as putting NS and K in vials that look the same. NO reason whatsoever. If we can do all we can to prevent an error, why not?
And yes, 16 hour shifts are unsafe. Don't tell me they are not.
Doesn't this negate your statement, "no one made med errors"?
Well, this was certainly not an AVOIDABLE med error caused by failing to practice the 5 Rights of Medication Admininstration--as well as carelessness--sloppiness--and not caring enough to properly calculate the dosage and double check that calculation with a co-worker before proceeding. It was also not a med error that resulted in patient harm. You have to admit that it was somewhat of a freak accident--I mean, who'd have ever thought that a gust of wind from a window that was frequently open would be strong enough to blow a med card off its hook, without taking a bunch of others with it? Still, that was apparently what occurred. I remember it like it was yesterday--as I said, it was a huge deal at our hospital.
While that patient did not get her 2 a.m. antibiotic, it wasn't because of any of the above factors, and she didn't suffer any ill effects. As I said, the most likely cause was the wind blowing the card off the med board. Still, the corpsman duly reported it--she did not lie, or pretend that she had given the med by charting that she had done so. She told the truth, even though she knew she would be held accountable, and she was. She took full responsibility.
My gosh, is it so difficult to believe that we, as young corpsmen, took a great deal of pride in our training and the responsibilities entrusted to us and didn't proceed with giving a medication unless we were absolutely sure it was the correct dosage, etc? It was an honor to take care of a patient then--it still is! Why do so many find that unfathomable? Is it so difficult to believe that I, and many others like me who originally trained in the military, and then went on to nursing school, continue to practice that way? I have no reason to be dishonest.
Have subsequent generations of nurses become so complacent that med errors are simply considered a given; a fact of life; something that they can't avoid; something that will happen to all of them at some point in our careers? I feel very differently.
I wouldn't GIVE a medication under poor lighting conditions--give me a single example, other than battlefield conditions, that you would HAVE to! If need be, get a flashlight and improve your lighting and thus your ability to see! And, with unit dose pretty much being the norm nowadays, as well as computerized labelling, when would one ever find a medication that was poorly labelled--and then proceed to give it anyway? Would more harm come from waiting than by giving a med that one was not even sure was the correct one and hoping for the best? Some of these scenarios just don't make any sense in the 21st century.
I am a clinically active operating room nurse. I also did home infusion and clinical IV teaching for a while. Now, if I have a question about a med I am giving or a dosage--or even if I have concerns about how I see someone ELSE attempting to give it-- I do not give it or hand it to that individual (say, an anesthesia provider) until I look it up, clarify the dosage with the PDR or a pharmacist, etc. I don't give a 10 fold overdose of a medication simply because the doctor wrote it that way, and then point fingers as an excuse. His stupidity is not a license for me to follow suit.
I am aware that we no longer write MS or MSO4. Why? Because, supposedly, a nurse would mistake, say, MgSo4 for what was actually written--MSO4--and give that instead. Now, I ask you--wouldn't a reaonable and prudent nurse QUESTION an order for Magnesium Sulfate in a patient that was not in OB and being treated for pre-eclampsia--a common use for this drug? Wouldn't this be an automatic red flag that would make her pause, think, and either call the doctor, call the pharmacist, look in the PDR or look it up on the internet before proceeding, foolishly, to give it? Wouldn't she wonder why her patient with severe pain didn't have Morphine or something similar ordered, and why he DID have Magnesium Sulfate--in an unusual dosage--even written? Wouldn't it follow suit that the medication is most likely Morphine, but, just to be sure, double check with the MD and/or the pharmacist? Why does everyone need to be spoonfed, for heaven's sakes? What ever happened to critical thinking and common sense?
It's unacceptable not to be aware of the proper dosages and acceptable routes of meds we are giving. For example, I do not give Phenergan via peripheral IV simply because "everybody else does it" or "our policy allows it or "we do it all the time and have never had a problem or, the classic "the doctor ordered it." I am aware of the problems that can occur and it doesn't bother me to tell a nurse administrator or a doctor no, I will not risk my license for them. I do not say, well, I am not familiar with INS standards and guidelines because they are not widely disseminated and, anyway, I don't want to purchase them--if I am going to be giving IV meds, I make it a point to FAMILIARIZE myself with them. Contrary to what many people believe, EVERY nurse giving IV meds is held to the standards and guidelines published by INS--NOT just IV certifed nurses.
I am glad that I practice in CA, where 30 CEs every 2 years is required to maintain one's license. I stay current on the drugs and their dosages and their routes of administration and their contraindications. I am not special in this regard--every CA nurse I know does the same. We strive to hold ourselves to higher standard than the minimum, and we expect our co-workers to do the same.
MEDICATION ERRORS ARE AVOIDABLE. Simple as that.
As for mandatory overtime, well, all I can say is "just say no." No apologies,no excuses. No one can make you a victim unless you allow them to do so.
Your hospital "forces" mandatory overtime on you, you say? Unionize or quit and get a better job with safer working conditions. Be proactive and get a safe staffing law passed, as we did in CA--don't sit and wait for someone else to do it for you. It won't happen. CA RNs, myself included, are very proud that we have the only safe staffing law, with stictly regulated RN to patient ratios, in the nation. WE, and CNA, made it happen. No one else was going to do it for us. This is one reason I choose to work as an oerating room nurse in CA--although I live in Oregon.
But mandatory overtime is the subject of a whole other thread, and it's already been done to death.
You may talk all you want about the painstaking calculations and unlabelled vials that you used, but the fact remains--none of that was safe.
I never said we used unlabelled vials--that would, indeed, be unsafe. I said we used STOCK medications--i.e., large containers of p.o. meds and vials that were a different dosage than what was ordered. There was no such thing as unit dose in the '70s. We managed just fine with what we had. We always had the PDR as our resource if there was any doubt about appropriate dosage if an order didn't seem right--and, of course, we talked to the doctor who wrote the order before proceeding.
Pharmaceutical math was unsafe? How do you think generations of pharmacists calculated their dosages? Not to mention nurses BEFORE the '70s? Granted, we did not have the luxury of calculators, which is why we checked, double checked and triple checked our calculations with another corpsman or RN before proceeding. It is, after all, simple algebra. We have all been taught to do it--technology nowadays has just made it unnecessary. However, then, it was standard of care.
Please don't tell me they have stopped teaching pharmaceutical math in nursing school!
well, this was certainly not an avoidable med error caused by failing to practice the 5 rights of medication admininstration--as well as carelessness--sloppiness--and not caring enough to properly calculate the dosage and double check that calculation with a co-worker before proceeding. it was also not a med error that resulted in patient harm. you have to admit that it was somewhat of a freak accident--i mean, who'd have ever thought that a gust of wind from a window that was frequently open would be strong enough to blow a med card off its hook, without taking a bunch of others with it? still, that was apparently what occurred. i remember it like it was yesterday--as i said, it was a huge deal at our hospital.
while that patient did not get her 2 a.m. antibiotic, it wasn't because of any of the above factors, and she didn't suffer any ill effects. as i said, the most likely cause was the wind blowing the card off the med board. still, the corpsman duly reported it--she did not lie, or pretend that she had given the med by charting that she had done so. she told the truth, even though she knew she would be held accountable, and she was. she took full responsibility.
my gosh, is it so difficult to believe that we, as young corpsmen, took a great deal of pride in our training and the responsibilities entrusted to us and didn't proceed with giving a medication unless we were absolutely sure it was the correct dosage, etc? it was an honor to take care of a patient then--it still is! why do so many find that unfathomable? is it so difficult to believe that i, and many others like me who originally trained in the military, and then went on to nursing school, continue to practice that way? i have no reason to be dishonest.
have subsequent generations of nurses become so complacent that med errors are simply considered a given; a fact of life; something that they can't avoid; something that will happen to all of them at some point in our careers? i feel very differently.
i wouldn't give a medication under poor lighting conditions--give me a single example, other than battlefield conditions, that you would have to! if need be, get a flashlight and improve your lighting and thus your ability to see! and, with unit dose pretty much being the norm nowadays, as well as computerized labelling, when would one ever find a medication that was poorly labelled--and then proceed to give it anyway? would more harm come from waiting than by giving a med that one was not even sure was the correct one and hoping for the best? some of these scenarios just don't make any sense in the 21st century.
i am a clinically active operating room nurse. i also did home infusion and clinical iv teaching for a while. now, if i have a question about a med i am giving or a dosage--or even if i have concerns about how i see someone else attempting to give it-- i do not give it or hand it to that individual (say, an anesthesia provider) until i look it up, clarify the dosage with the pdr or a pharmacist, etc. i don't give a 10 fold overdose of a medication simply because the doctor wrote it that way, and then point fingers as an excuse. his stupidity is not a license for me to follow suit.
i am aware that we no longer write ms or mso4. why? because, supposedly, a nurse would mistake, say, mgso4 for what was actually written--mso4--and give that instead. now, i ask you--wouldn't a reaonable and prudent nurse question an order for magnesium sulfate in a patient that was not in ob and being treated for pre-eclampsia--a common use for this drug? wouldn't this be an automatic red flag that would make her pause, think, and either call the doctor, call the pharmacist, look in the pdr or look it up on the internet before proceeding, foolishly, to give it? wouldn't she wonder why her patient with severe pain didn't have morphine or something similar ordered, and why he did have magnesium sulfate--in an unusual dosage--even written? wouldn't it follow suit that the medication is most likely morphine, but, just to be sure, double check with the md and/or the pharmacist? why does everyone need to be spoonfed, for heaven's sakes? what ever happened to critical thinking and common sense?
it's unacceptable not to be aware of the proper dosages and acceptable routes of meds we are giving. for example, i do not give phenergan via peripheral iv simply because "everybody else does it" or "our policy allows it or "we do it all the time and have never had a problem or, the classic "the doctor ordered it." i am aware of the problems that can occur and it doesn't bother me to tell a nurse administrator or a doctor no, i will not risk my license for them. i do not say, well, i am not familiar with ins standards and guidelines because they are not widely disseminated and, anyway, i don't want to purchase them--if i am going to be giving iv meds, i make it a point to familiarize myself with them. contrary to what many people believe, every nurse giving iv meds is held to the standards and guidelines published by ins--not just iv certifed nurses.
i am glad that i practice in ca, where 30 ces every 2 years is required to maintain one's license. i stay current on the drugs and their dosages and their routes of administration and their contraindications. i am not special in this regard--every ca nurse i know does the same. we strive to hold ourselves to higher standard than the minimum, and we expect our co-workers to do the same.
medication errors are avoidable. simple as that.
as for mandatory overtime, well, all i can say is "just say no." no apologies,no excuses. no one can make you a victim unless you allow them to do so.
your hospital "forces" mandatory overtime on you, you say? unionize or quit and get a better job with safer working conditions. be proactive and get a safe staffing law passed, as we did in ca--don't sit and wait for someone else to do it for you. it won't happen. ca rns, myself included, are very proud that we have the only safe staffing law, with stictly regulated rn to patient ratios, in the nation. we, and cna, made it happen. no one else was going to do it for us. this is one reason i choose to work as an oerating room nurse in ca--although i live in oregon.
but mandatory overtime is the subject of a whole other thread, and it's already been done to death.
several points here i want to address
1) mag sulphate is used for far more than just ob
2) double and triple checking are fine if there is the staff!!!
3) dismissing mandatory overtime like you have diminishes all of those who are tied into the system and cannot escape - and yes there are those people.
4) it is obvious you have not worked night shift on a ward lately - yes there are times when the lighting is less than adequate even with a torch.
5) never underestimate the power of suggestion and peer pressure. if people will give a lethal electrical shock during a controlled experiment then they will give a medication "because a doctor told them to"
[color=#008080]in the experiment, so-called "teachers" (who were actually the unknowing subjects of the experiment) were recruited by milgram. they were asked administer an electric shock of increasing intensity to a "learner" for each mistake he made during the experiment. the fictitious story given to these "teachers" was that the experiment was exploring effects of punishment (for incorrect responses) on learning behavior. the "teacher" was not aware that the "learner" in the study was actually an actor - - merely indicating discomfort as the "teacher" increased the electric shocks.
[color=#008080]when the "teacher" asked whether increased shocks should be given he/she was verbally encouraged to continue. sixty percentof the "teachers" obeyed orders to punish the learner to the very end of the 450-volt scale! no subject stopped before reaching 300 volts!
[color=#008080]at times, the worried "teachers" questioned the experimenter, asking who was responsible for any harmful effects resulting from shocking the learner at such a high level. upon receiving the answer that the experimenter assumed full responsibility, teachers seemed to accept the response and continue shocking, even though some were obviously extremely uncomfortable in doing so. the study raised many questions about how the subjects could bring themselves to administer such heavy shocks. more important to our interests are the ethical issues raised by such an experiment itself. what right does a researcher have to expose subjects to such stress? what activities should be and not be allowed in marketing research? does the search for knowledge always justify such "costs" to subjects? who should decide such issues?
i think you are seriously underestimating the effect of peer pressure. i am glad though that you do believe you can yourself resist this in every instance in every clinical situation. i sincerely hope you are right in that belief because we do need people who can say no.
2) double and triple checking are fine IF THERE IS THE STAFF!!!
3) Dismissing mandatory overtime like you have diminishes all of those who are tied into the system and cannot escape - and yes there are those people.
4) It is obvious you have not worked night shift on a ward lately - yes there are times when the lighting is less than adequate even with a torch.
5) NEVER underestimate the power of suggestion and peer pressure. If people will give a lethal electrical shock during a controlled experiment then they will give a medication "because a doctor told them to"
I think you are seriously underestimating the effect of peer pressure. I am glad though that you do believe you can yourself resist this in every instance in every clinical situation. I sincerely hope you are right in that belief because we do need people who can say no.
Actually, Gwenith, with all due respect, I worked 12 hour night shifts as recently as 1 year ago, in hospitals all over the West Coast--I was there to round on all the floors and teach the staff the proper use of various infusion products and pumps.
I saw NONE of the poor lighting that you describe--in fact in most cases, I wondered how some of the poor patients ever got any sleep. In addition, since CA for a while had frequent power outages (rolling blackouts) we were supposed to be mindful about turning off unneeded lights--however, it was rarely done, which continued to contribute (supposedly--although Enron was a culprit) to rolling blackouts. Nevertheless, due to earthquakes, etc. CA has always had emergency generators in their hospitals to fall back on which are superb. In fact, I (and others) have completed more than one emergency trauma surgery on generator power only, especially during my years of taking night call--not tooooo long ago--'90s.
Still Mag Sulfate, regardless of how and where it's used, wouldn't have a dosage similar enough to Morphine to cause confusion between the 2, would it? I'd have to look it up, and would do so if I ever saw an order for it--it's not a drug we ever use in surgery, and I've never used it for anything except when I worked L&D long ago, for preeclampsia. The fact that I haven't used it in so long is even MORE reason for me to aquaint myself with the proper dosage, administration, etc. before I took it upon myself to give it to any patient----absolutely no excuse to mindlessly give a drug that I have not used in years, just because I THOUGHT that's what the order read.
Not enough staff on the floor to double check a questionable dosage before proceeding? Call the night supervisor or walk over to another floor, or call the pharmacy. Call the inhouse anesthesiologist, if one is available. I think these are fairly easy problems that are easily circumvented. After all, we aren't working in 3rd world countries or, as I said earlier, under battlefield conditions.
I am well aware of the potential for error from my ER experiences as a pt. Many a doc is still hellbent on giving me stuff I'm allergic to. I guess they don't believe me and think I'm just snowing them. For this reason I always ask before a nurse gives me anything, "What is it and how much." Then of course you know how I'm viewed after that.
One of these days I'm going to shut my mouth..let them inject me and sue the doctor after.
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actioncat
262 Posts
Stevie,
Frankly, I would be a little scared to go to a facility where there were "never any med errors".
There is a reason not to be punitive with errors and to look at the system-- we want to make sure that workers report their errors so corrections can be made as soon as possible.