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.
Me, arrogant? :chuckle I am probably the most laid back person I know.
Ah, I thought so.
California is the role model in how to affect change in nursing and we in Florida are years behind in changing our attitudes and paradigms, etc. So they have a right to be a proud. But just because we are a bit behind, doesn't mean we are lazy, stupid, and doormats willing to sit quietly and be abused. But we have a long way to go........sigh.
My compliments to everyone for making this a productive and interesting thread. I don't have anything to add, but you all deserve a pat on the back for disagreeing and learning from each other because of the differing opinions. Good job.
Ok, I can't hold back any longer! LOL I am the nurse clinician for the ICU I work in, prior to this I spent 6+ years in a specialized open heart unit. The potential for med error was and is always apparent. It is a VERY avoidable thing, just as Stevie has said.
I can relate to your comments Stevie, regarding inservicing. Nothing is more frustrating then spending hours at work and hours at home preparing an inservice, researching and formatting and gathering and reformatting and presenting and then presenting again, and again, and again, to only have someone throw your handouts in the garbage, or talk and giggle during your discussion, or ask for food, or fall asleep. What people fail to realize is the information provided is vital to giving excellent, competent care. And, while there are those who listen attentively and ask questions there are those who quite frankly could care less. I am human, I am fallible and I know that I make mistakes and will continue to do so, but this is my nursing liscence, something I worked hard for, and I will be doggoned if something as avoidable as a med error will take it away. It takes only a few seconds to do a double/triple check. It is worth to me, and I will always do it. I am thankful to God every day that I made it through the day without making a mistake. I am thankful to my instructors and preceptors who emphasized the importance of checking medications to me. I only hope that I have as much affect on those that I teach. There for the grace of God go I.
#2 - gwenith said something to the effect that it is "great to double check doseages when you have available staff"...hmmm... convienance over safety:nono:
when my mom was in the hospital (chemo), the nurse got all huffy when i asked her to show me how she calculated the dose. wrong attitude (but i probably cost her an extra 3.5 minutes by doing that, so i understand her frustration). if a patient asks, they are not implying fault on your part so get over it. it was a safety measure - and i do it (and will continue to do it) every time - for every drug, for every iv solution, for every member of my family!
#3 - i cannot even count the times i have received blood tubes in the lab that had nothing identifying them.... and then the nurses call down saying, "i know it was mr x's blood....." or "i drew it from room 2 but had room 12's chart in hand and placed wrong stickers on tubes ... blahhh.. blahh.... blahhh" ....sorry. do it right the next time you do it because what you sent is in the trash. (this is a real pet peeve and a huge problem). anyway the nurse at fault gets all bent because i won't let her "just put another sticker on the tube"
#4 - why do we have patients sign the site for surgery - why is a "time out" required in the or or other invasive procedures now? bottom line: safety is compromised when short cuts are taken due to convienance ("i didn't have enough time"). luckily, not many people die because someone was in a hurry ...but, then again 1 death due preventable mistake is 1 too many.
i am not bashing nurses. the theory applies equally to all departments and individuals in the hospital.
My compliments to everyone for making this a productive and interesting thread. I don't have anything to add, but you all deserve a pat on the back for disagreeing and learning from each other because of the differing opinions. Good job.
And Tweety is a good facilitator, isn't he? I'll bet he'd make a great mediator--or union steward....or attorney....
I am NOT bashing nurses. The theory applies equally to all departments and individuals in the hospital.
Good post, I can't disagree with anything. Errors that are happening are preventable with very little effort.
But to simply say, "that was preventable....end of discussion" doesn't address the fact that 10's of thousands of preventable errors occur yearly, many resulting in death. Why aren't people doing their jobs properly and killing people? Can anything be done do stop it? More education? Better weeding out of incompetent people? Hidden cameras in med rooms and patient rooms? Harsh punishments? I don't have any answers.
But to sit in judgement and close our minds to anything we can do to help may safe a life or two as well.
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 had the same reaction. If everyone was this harsh and punitive then no one would report errors when they occur and there would be no changes made to ensure that the error NEVER occurs again. That is the reason for non-punitive error reporting, to encourage professionals to accept the reality of errors and to take steps to learn from them and create safer systems.
Of course it is horribly sad for this patient and her family. It is also sad for everyone else involved, what a difficult thing to live with knowing you have been involved in such a horrific incident. I feel for everyone in this scenario.
In the entire time I was there, that's the only med error I ever heard about.
And I will bet that it is responses like the one you describe (busting the corpsman down a paygrade etc.) that caused people to learn how to be more furtive and cover up their errors, in my not so humble opinion.
Specializes in Vents, Telemetry, Home Care, Home infusion.
copied from nsg news forum:
from ana news:
new alliance to address global problem of patient safety
11/01/04
the world health organization (who) and other partners has announced a series of key actions to cut the number of illnesses, injuries and deaths suffered by patients during health care, with the launch of the world alliance for patient safety.
the new alliance which includes who, senior health officials, academics and patients' groups have agreed to work together to reduce the adverse health and social consequences of health care. a number of countries have already initiated patient safety plans and legislation. political leaders from several countries are playing a key role in supporting the development of research, delivery capabilities and knowledge to tackle the full range of patient safety issues on a worldwide scale. two partners of the alliance - the department of health of the united kingdom and the u.s. department of health and human services - are committing resources and expertise to start reversing the escalating incidence of preventable adverse effects in health-care. read complete press release at www.who.int/mediacentre/news/releases/2004/pr74/en.
Possibly true. PROBABLY true. I never really thought about med errors being made and not reported--it was just soooo drilled into us in corps school that we needed to always, always ALWAYS double check or even triple check our meds--ESPECIALLY insulin and heparin, with another person--that we always did so--at least the people I worked with did. So, if there were math errors on the first calculation (I am referring to when we had to calculate our dosages mathematically) it would SEEM that they'd be caught by the person doing the double checking--usually an RN, and Navy RNs were very highly educated and sophisticated--and thus the potential administration error caught and prevented.
However, I guess it's entirely possible that 2 people could make the same miscalculation and never even be aware of it--thus making a med error--and I guess it's entirely possible that there were corpsmen that never even bothered to have their calculations double checked, or those who blatantly covered up their med errors--i.e., charted tha tthey gave a med when they really did not--- and were lucky enough not to get caught. I guess I am naive enough to think that if I wouldn't lie, then neither would anyone else. I worked with a really good, conscientious group of people at each of my duty stations.
At our small Navy hospital in Rhode island, if indeed there was a med error committed that was reported and caused harm, you can bet the entire hospital would have known about it--even if the pending captain's mast would have been kept top secret, word would have leaked out from someone who worked in the captain's office--not to mention people would wonder why someone was now wearing one less stripe and not doing direct patient care anymore.
But, you are absolutely correct--just because none were ever reported doesn't mean, absolutely, that none occurred.
Even in the '80s and '90s, in civilian life, surgical complications (and perhaps med errors?) that caused no visible or obvious harm were seldom recorded on anything but an incident report, which was not discoverable. That deceitful atmosphere, which always bothered me, has fortunately changed, and things that were usually not disclosed to the patient (unless they suffered visible or otherwise obvious harm, and then there was no way around it) now are not only recorded in the permanent medical record, but are divulged immediately. It's simply the right thing to do.
Speaking of which, now I just read a little news article --the first I have seen about the Washington case--that says that a big picture fell off the wall, onto the head of the woman who died of the Chlorhexidine injection, while she was sitting in some waiting room at VM about a month before the Chlorhexidine incident. WTF?!!!
NOW VM is saying that, had it not been for that good fortune (the picture falling on her head and her subsequent CT scan,) she would never have known she had an aneurysm. I can't figure out why they are divulging this info--I mean, are they trying to suggest that, after all, the family should not be angry because, if not for VM causing her head trauma in the first place, she would have gone undiagnosed and probably died of a ruptured cerebral aneurysm? And perhaps the family should keep that in mind if they even THINK about suing? This whole thing is getting "curiouser and curiouser."
You say that the Navy RNs were very highly educated and sophisticated........when I was in the Navy I worked with some nurses fresh out of nursing school that didn't even know how to take vital signs, give meds, or transfer a patient.
Also when I was in the Navy, a friend going for shoulder surgery had requested general anesthetic. The Doc told him no, he was going to give him local anesthetic. During the procedure of giving him local anesthetic, the Doc gave him a pneumothorax and then decided, since the local anesthetic "wasn't working" that he was going to put him under general anesthesia. My friend could have died, as obviously a pnuemothorax plus general = trouble.
Because of the Navy 'no sue' policy, nothing could be done....after my friend spent 2 weeks in the hospital, and had to go back later to redo his surgery.
Tweety, BSN, RN
36,304 Posts
Ah, I thought so.
California is the role model in how to affect change in nursing and we in Florida are years behind in changing our attitudes and paradigms, etc. So they have a right to be a proud. But just because we are a bit behind, doesn't mean we are lazy, stupid, and doormats willing to sit quietly and be abused. But we have a long way to go........sigh.
Carry on now. I love a good debate.