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.
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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.
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.
Well, it's nice to know that you are perfect, infallible, and never make a mistake. Thank you for sharing that with the rest of us.
well this ismore info than i had previously seen. it is interesting but it also a tad slanted against vmmc, i personally liek reporting that is unbiased, i admit this does sound like someone with appropriate medical knowledge but it also sounds like a lawyer, which in my opinion is always going to slant toward wrong to be admonished.
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.
GEE.I think I need to work in CA where the working conditions sound exceptional!!!!!Night supervisor??what is that?? Oh yea, that is the person who works one night and has to do 4 nurses jobs and never comes back, so you never have one..walk to another floor?? and get written up for leaving your floor and a family member saw you and because you have no business leaving the floor (even to eat) you sure as hell better not leave for any other reason..this could be grounds for immediate dismissal...hospital,nursing home,rehab facility..do they have in house anesthesiologist that will come to you?????? You might not be working in 3rd world conditions but the rest of the country is struggling with lack of proper working conditions and burnt out management and nurses....I mean have you read this board at all???????????????????????????? Do not get me wrong.. I love being a nurse but the frustrations of not being able to care properly for my pts is at times overwhelming...that is why there is a nursing shortage and that is why there are med errors and that is why good nurses struggle every day to give the best care they can....I must stop now because my soapbox is bigger than this forum can hold..........
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 hardly think that rounding on all the floors and teaching the staff the proper use of various infusion pumps and products equates to actually working a 12 hour night shift.
GEE.I think I need to work in CA where the working conditions sound exceptional!!!!!Night supervisor??what is that?? Oh yea, that is the person who works one night and has to do 4 nurses jobs and never comes back, so you never have one..walk to another floor?? and get written up for leaving your floor and a family member saw you and because you have no business leaving the floor (even to eat) you sure as hell better not leave for any other reason..this could be grounds for immediate dismissal...hospital,nursing home,rehab facility..do they have in house anesthesiologist that will come to you?????? You might not be working in 3rd world conditions but the rest of the country is struggling with lack of proper working conditions and burnt out management and nurses....I mean have you read this board at all???????????????????????????? Do not get me wrong.. I love being a nurse but the frustrations of not being able to care properly for my pts is at times overwhelming...that is why there is a nursing shortage and that is why there are med errors and that is why good nurses struggle every day to give the best care they can....I must stop now because my soapbox is bigger than this forum can hold..........
Let me say again--people will only do to you what you ALLOW them to do to you. Don't put up with inferior working conditions--advocate for yourself. Get out there and lobby. Write letters. CA nurses did--I remember back when I first started as a CA nurse in '81. We weren't afraid to get out there and make our voices heard and strike if necessary. Now we have the ONLY safe staffing law, with minimum RN to patient ratios in the nation.
But, if you'd rather complain to an anonymous BB about how inferior your working conditions are, rather than expressing the same sentiments, both in writing and verbally, LOUDLy, to the politicians who have the power to make a difference, feel free.
I hardly think that rounding on all the floors and teaching the staff the proper use of various infusion pumps and products equates to actually working a 12 hour night shift.
Well--YOU try working at a hospital like Cedars Sinai (just one of many) which is something like 16 floors, each subdivided into 4 big sections, each of which requires a SEPARATE inservice, (and then going back over and over and doing MORE individual inservices, for those who were sleeping or on a dinner break while you taught the group one) walking literally miles a night because you must cover EVERY floor and EVERY person on those floors, losing your voice and giving inservice after inservice after inservice, both group and individual, troubleshooting problems one after another because more than one person didn't want to be bothered with listening to your inservice in the first place because "I don't DO IVs--I just call the supervisor" and whose main concern was "Where's the candy? Did you bring candy?" Then report your experience back to us.
Don't get me wrong--I loved doing this job, just as I loved my years of taking trauma call. I've paid my dues. Operating room nurses work just as hard as floor nurses, believe it or not.
gosh stevie, I'm trying to figure out why you have been so rude on this board, but I dont know....oh well, I'm done with this thread.
How have I been rude in ANY way? My gosh, I was just thinking the same thought about the nasty comment directed at me that I responded "no need for cattiness" to. Aren't we all here to learn from each other? How is my pointing out, gently, that maybe people who do nothing but complain about their adverse working conditions--which translate to suboptimal patient care--ought to divert some of that energy to complaining to those who have the power to CHANGE things? No, then they wouldn't have anything to complain about, and then they would no longer be victims. I love working as an RN in CA, and I am proud of CA colleagues and the CNA for giving us a voice. I have never had to complain about my working conditions--but, then, if I was unhappy at a place, I would get the hell out of that place--not suffer or complain to people who cannot effect change. Fortunately, my experience in CA is different than some RNs from other states report--everywhere I have been lucky enough to work as an OR nurse, either staff, per diem or traveler, we have been treated as professionals and the supervisors were sophisticated enough to listen to us and GIVE us the tools needed ot do our jobs--well.
You can look at anything I have EVER posted on this BB and see that I am anything BUT rude.
But, I guess you can read anything you want to into a post. Sometimes people simply are uncomfortable with hearing the truth.
Well--YOU try working at a hospital like Cedars Sinai (just one of many) which is something like 16 floors, each subdivided into 4 big sections, each of which requires a SEPARATE inservice, walking literally miles a night because you must cover EVERY floor and EVERY person on those floors, losing your voice and giving inservice after inservice after inservice, both group and individual, troubleshooting problems one after another because more than one person didn't want to be bothered with listening to your inservice in the first place because "I don't DO IVs--I just call the supervisor" and whose main concern was "Where's the candy? Did you bring candy?" Then report your experience back to us.
Don't get me wrong--I loved doing this job, just as I loved my years of taking trauma call. I've paid my dues. Operating room nurses work just as hard as floor nurses, believe it or not.
I bet you don't administer many meds in the operating room, though.
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