JJR512
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Complete article: http://www.tmz.com/2007/11/20/dennis-quaids-twins-in-medical-nightmare/
Dennis Quaid's Newborn Twins in Medical Nightmare
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firetender
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no one's immune from tragedy, and this is off the charts. Prayers, everyone for everyone.
Ridryder911
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Heparin is probably one of the most "accidental and wrong" dosage medications given. The problem is that dosagen numbers given is small, the color coding is very similar, and one has to usually dilute the solution when less than a 1000 units.
I have to admit, I hate mixing Heparin flushes, and small volumes. Many assume you just add saline to the mixture but that is not correct, to really get the proper proportion.
I too wish them good health, they have a long fight, as well as my thoughts are to the nurse that accidentally administered the wrong dosage, and is probably grieving as well. Everyone makes mistakes, but unfortunately this will be costly.
I found it ironic, that most national coverage jumped on the band wagon of how much ..."wrong and improper dosages are given daily to patients".... Of course nothing was mentioned that medical staff is short handed, one has to multi-task and attempt to figure dosages and conversions, etc.
As well, their easy blanket solution was to "bar code" and then the patient would get the right dosage (of course information sponsored by the bar code manufacture) and they left out that special dosages such as Heparin mixture has to be hand mixed per weight dependent and could not be "bar coded".
R/r 911
I have to admit, I hate mixing Heparin flushes, and small volumes. Many assume you just add saline to the mixture but that is not correct, to really get the proper proportion.
I too wish them good health, they have a long fight, as well as my thoughts are to the nurse that accidentally administered the wrong dosage, and is probably grieving as well. Everyone makes mistakes, but unfortunately this will be costly.
I found it ironic, that most national coverage jumped on the band wagon of how much ..."wrong and improper dosages are given daily to patients".... Of course nothing was mentioned that medical staff is short handed, one has to multi-task and attempt to figure dosages and conversions, etc.
As well, their easy blanket solution was to "bar code" and then the patient would get the right dosage (of course information sponsored by the bar code manufacture) and they left out that special dosages such as Heparin mixture has to be hand mixed per weight dependent and could not be "bar coded".
R/r 911
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JJR512
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So what is the right solution?
More specifically: What is the right solution in an ideal world, and what is the best right solution in the world in which we actually live?
More specifically: What is the right solution in an ideal world, and what is the best right solution in the world in which we actually live?
Ridryder911
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Have patient medication mixed per pharmacist and double checked before administration. (many hospitals now require this). Having enough nursing staff, so rush in administration of medications can be performed safely using the 5 "R". As well, as having "cheat" references available (computer could be used as a back up).
They may have availability now, but usually staff is too rushed to be able to use it.
R/r 911
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JJR512
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I couldn't tell from the article, so I'm not sure if the nurse who administered the heparin overdose made the mistake because she was rushed, as you're talking about, or because she was complacently careless, expecting one thing to be where she found it but it was something else because a tech put the wrong thing there. If the nurse is used to the one thing always being there, she might not have double-checked it as she should have, but I think that's more from complacency than being rushed.
This reminds me of a pediatric patient I recently transported who, while in the ED, had accidentally been given a double dose of Tylenol. A nurse saw an order for the Tylenol in the new orders area and so administered it, but when she went to record this on the administered meds chart, she saw someone else had already administered it. Poison control was contacted, and they determined there was no problem because the patient hadn't had any other Tylenol in the past 24 hours, and the total amount given wasn't a harmful amount. I'm not sure what the standard procedure is in that ED for giving meds; perhaps the order is supposed to be moved to a different part of the chart when it's completed, or perhaps the nurse was supposed to check the meds given chart before carrying out the order. Whatever the standard procedure is, clearly it wasn't followed in this patient's case.
I'm not sure, though, if "having enough nursing staff" is really a viable solution, especially the way I qualified the question. To me, that sounds more like an ideal solution. Why don't they have enough nurses already? Isn't there a shortage of healthcare providers at all levels? And how are they going to be paid?
I think that part of the solution is already in place. This hospital apparently has designated places where particular things are supposed to be stored. Hopefully, that's a universal, or at least extremely common, policy in hospitals. But two mistakes were made, either of which wouldn't have been a big deal on its own had the other also not have occurred. One mistake was the tech putting the wrong thing in the wrong place. The other was the nurse not checking what she was using, what she expected to find in that place. Had the tech put the right thing in that place, it wouldn't have mattered (in the practical end result) that the nurse didn't check it, because she would have been using the right thing. Or, had the tech made his mistake but the nurse not made hers, and she checked it before using it, she would have caught the mistake and found the right thing that she was supposed to be using.
So the hospital needs to analyze how this happened and see what can be done to reduce the chance of it happening again. Only that hospital can really do that, because only they know what their policies and practices are; the rest of us are just guessing and throwring out "what-ifs". Ultimately, of course, there can be no way to completely eliminate the chance of a mistake happening, or even a confluence of mistakes.
This reminds me of a pediatric patient I recently transported who, while in the ED, had accidentally been given a double dose of Tylenol. A nurse saw an order for the Tylenol in the new orders area and so administered it, but when she went to record this on the administered meds chart, she saw someone else had already administered it. Poison control was contacted, and they determined there was no problem because the patient hadn't had any other Tylenol in the past 24 hours, and the total amount given wasn't a harmful amount. I'm not sure what the standard procedure is in that ED for giving meds; perhaps the order is supposed to be moved to a different part of the chart when it's completed, or perhaps the nurse was supposed to check the meds given chart before carrying out the order. Whatever the standard procedure is, clearly it wasn't followed in this patient's case.
I'm not sure, though, if "having enough nursing staff" is really a viable solution, especially the way I qualified the question. To me, that sounds more like an ideal solution. Why don't they have enough nurses already? Isn't there a shortage of healthcare providers at all levels? And how are they going to be paid?
I think that part of the solution is already in place. This hospital apparently has designated places where particular things are supposed to be stored. Hopefully, that's a universal, or at least extremely common, policy in hospitals. But two mistakes were made, either of which wouldn't have been a big deal on its own had the other also not have occurred. One mistake was the tech putting the wrong thing in the wrong place. The other was the nurse not checking what she was using, what she expected to find in that place. Had the tech put the right thing in that place, it wouldn't have mattered (in the practical end result) that the nurse didn't check it, because she would have been using the right thing. Or, had the tech made his mistake but the nurse not made hers, and she checked it before using it, she would have caught the mistake and found the right thing that she was supposed to be using.
So the hospital needs to analyze how this happened and see what can be done to reduce the chance of it happening again. Only that hospital can really do that, because only they know what their policies and practices are; the rest of us are just guessing and throwring out "what-ifs". Ultimately, of course, there can be no way to completely eliminate the chance of a mistake happening, or even a confluence of mistakes.
Ridryder911
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Unfortunately, common sense does not always makes sense to management. Shortage in health care, definitely. Part of the problem is why would want to be under undue stress, and be responsible for such, when one can make more money, less education, less, stress in other markets? Hence, the reason the average age of a nurse is now 52 years old.... now, think what medicine will be like in 10 years. As well, these babies are in a specialty care unit. Yes, there is shortage in health care except for EMT's... and their abundant. Unfortunate for our profession.
Sure, we can say one should be more careful. Read the charts better, etc. All thoughts that should be stressed and goals however; let's look at the real world. Multiple physician orders, many that cancel each others out. Change in vendors or brands that changes labels weekly, and technically one should have another licensed practitioner to verify orders such for Heparin, Insulin and some others but again in the real world... What many people do not understand is the number of medications administered at periods of time. I remember administering over 100 capsules, pills in one hour to < 7 patients. Now, compound this at least three times a day, times number of patients. Again, not like EMS that usually has preload, limited number of medications, and very little add mixture that is performed, and time duration to be administered.
Yes, medication orders are drastic and have became unreasonable. Yes, measures such as "bar code" that matches with patients, pharmacists that perform all add mixtures, and enough staff to perform administration. JCAHO, is very aware of the recent problems, and is highly recommending bar coding for patient care. Even my small rural ER, have went to this device for most "non-emergency" medications. It provides safety, documents time administered, and as well automatically bills the patient. The costs of devices costs is astronomical but if it saved one life it would be worth it... and yet again, maybe hire appropriate number of staff...
There is no easy answer, and more medications administered in the field, we will see more errors occur as well there too. I have read of medics not administering medications due to the complexity of "mixing it and giving it right".. which is scary and down right negligible.
R/r 911
Sure, we can say one should be more careful. Read the charts better, etc. All thoughts that should be stressed and goals however; let's look at the real world. Multiple physician orders, many that cancel each others out. Change in vendors or brands that changes labels weekly, and technically one should have another licensed practitioner to verify orders such for Heparin, Insulin and some others but again in the real world... What many people do not understand is the number of medications administered at periods of time. I remember administering over 100 capsules, pills in one hour to < 7 patients. Now, compound this at least three times a day, times number of patients. Again, not like EMS that usually has preload, limited number of medications, and very little add mixture that is performed, and time duration to be administered.
Yes, medication orders are drastic and have became unreasonable. Yes, measures such as "bar code" that matches with patients, pharmacists that perform all add mixtures, and enough staff to perform administration. JCAHO, is very aware of the recent problems, and is highly recommending bar coding for patient care. Even my small rural ER, have went to this device for most "non-emergency" medications. It provides safety, documents time administered, and as well automatically bills the patient. The costs of devices costs is astronomical but if it saved one life it would be worth it... and yet again, maybe hire appropriate number of staff...
There is no easy answer, and more medications administered in the field, we will see more errors occur as well there too. I have read of medics not administering medications due to the complexity of "mixing it and giving it right".. which is scary and down right negligible.
R/r 911
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I'm sure there will be a root cause analysis on the chain of events that occured (among other safety measures/checks & balances). Medication errors are a big problem in health care organizations.
This is a very realistic event that while it has occurred to a famous person's babies, there are many, many medical errors occurring frequently with all age groups both at home and in the hospitals.
The average number of medications an elderly person takes is 12. Each of those medications may be taken 2 - 4 times per day. For those of you who don't fully appreciate a nurse at a nursing home, think about the number of medications she/he is responsible for. Lets be conservative and say the nurse is only covering 20 pts x 12 meds for the 0900 rounds. That is 240 meds that must be gathered along with administration notes such as with food or without food, to crush or not to crush, swallow precautions, fluid restriction, etc. Two hours each morning is dedicated to getting the meds ready. The next 2 - 3 hours are spent giving the meds either IM, IV, PO, PR, Inhalation or pushing them down G-tubes that may or may not be clogged.
While the medications are time consuming and frustrating, a patient might need more medical attention or the nurse has to get 3 or 4 patients ready for transport. After each interruption the nurse must be able to return to "passing" the meds which is definitely not as easy as it seems to some. After first med rounds, the nurse must start preparing for the 2nd round that is due between 1200 and 1300 plus insulin checks for each meal with probably at least 10 of the 20 pts having different insulins and different scales.
In the hospital, and definitely in the NICU, besides each unit having 2 machines like the one RID described, there are closets of pre-mixed solutions that all look alike but each are very different. Saline alone can be 0.18%, 0.22%, 0.45%, 0.9%, 3%, 7%, and 10%. The last two are usually for Respiratory Therapy. But, JCAHO now requires RT to store their meds in with nursing. Hypertonic saline just like high concentrations of heparin can be deadly. So, with the good intentions of "safety", the regulating agencies have created more potential for problems in some areas.
The old rules for neo/peds I had learned a long time ago as a new paramedic were definitely challenged when I started to work in a NICU. For example, "if it fits in a 1 cc syringe". I found many different concentrations for many different uses can fit in that 1 cc syringe just as well but not be appropriate. There is also the tallying of the total number of fluids and concentrations as well as each different flush solution. Besides the IV, there will be an arterial line that some babies may require hourly ABGs. Each flush as well as maintenance of that line must be taken into consideration. Every time a fluid rate is changed, all the medications and/or electrolytes in that fluid must be recalculated. The concentration of the solution or medication may have to be changed to accomondate the rate change. The nurse will have to be the first to pick up an error if it is missed by the doctor or pharmacy. This must occur before the baby picks up the error. The nurse must have intense knowledge of every fluid, electrolye and medication given. Ongoing education is a must to stay sharp whether it is provided by the facility or the individuals care enough about their license to stay current.
I am not a fan of "mail-order" nursing schools that many paramedics choose because there are so many things that a student should be made aware of in their clinicals that can prevent medical errors or frustration later when trying to administer various meds by various routes. Even becoming familiar with the pill crushing and which pills crush and which don't go well with a G-tube play an important part no matter how boring it might seem to those who thrive on an adrenaline rush. There's nothing like have experienced people around when you are learning to point out some of the little things that can go wrong or how to make something go more right. Just having someone to point out similarities in packaging can make a big difference. Many times those experienced people may have learned something the hard way themselves. When paramedics don't think they "need all the floor nursing stuff in clinicals", they don't know what they don't know. Besides just the routine patient hygiene things, there are so many things you are not going to get in any book even a pharmacology text or the Nursing "Bibles" by Lippincott. On the job in the ICU/ED is not the time to be fumbling with the little quirks of medication administration. This applies also to the new paramedic graduate on the streets.
I posted this article earlier this year as an awareness for the number of things that can go very wrong for a patient anywhere in the healthcare system.
http://www.emsresponder.com/features/article.jsp?id=5774&siteSection=4
I have made a few medication errors myself over the years. Fortunately I have caught them just before delivery. The one exception I didn't catch was as an RRT. I gave Atrovent which is pretty routinely given everywhere along with Albuterol. I was in a hurry and did not check for glaucoma meds or history. Although it happens very rarely that it is narrow angle glaucoma, which still is not a good defense, the patient's eye sight was compromised for a few very long hours for both of us.
The average number of medications an elderly person takes is 12. Each of those medications may be taken 2 - 4 times per day. For those of you who don't fully appreciate a nurse at a nursing home, think about the number of medications she/he is responsible for. Lets be conservative and say the nurse is only covering 20 pts x 12 meds for the 0900 rounds. That is 240 meds that must be gathered along with administration notes such as with food or without food, to crush or not to crush, swallow precautions, fluid restriction, etc. Two hours each morning is dedicated to getting the meds ready. The next 2 - 3 hours are spent giving the meds either IM, IV, PO, PR, Inhalation or pushing them down G-tubes that may or may not be clogged.
While the medications are time consuming and frustrating, a patient might need more medical attention or the nurse has to get 3 or 4 patients ready for transport. After each interruption the nurse must be able to return to "passing" the meds which is definitely not as easy as it seems to some. After first med rounds, the nurse must start preparing for the 2nd round that is due between 1200 and 1300 plus insulin checks for each meal with probably at least 10 of the 20 pts having different insulins and different scales.
In the hospital, and definitely in the NICU, besides each unit having 2 machines like the one RID described, there are closets of pre-mixed solutions that all look alike but each are very different. Saline alone can be 0.18%, 0.22%, 0.45%, 0.9%, 3%, 7%, and 10%. The last two are usually for Respiratory Therapy. But, JCAHO now requires RT to store their meds in with nursing. Hypertonic saline just like high concentrations of heparin can be deadly. So, with the good intentions of "safety", the regulating agencies have created more potential for problems in some areas.
The old rules for neo/peds I had learned a long time ago as a new paramedic were definitely challenged when I started to work in a NICU. For example, "if it fits in a 1 cc syringe". I found many different concentrations for many different uses can fit in that 1 cc syringe just as well but not be appropriate. There is also the tallying of the total number of fluids and concentrations as well as each different flush solution. Besides the IV, there will be an arterial line that some babies may require hourly ABGs. Each flush as well as maintenance of that line must be taken into consideration. Every time a fluid rate is changed, all the medications and/or electrolytes in that fluid must be recalculated. The concentration of the solution or medication may have to be changed to accomondate the rate change. The nurse will have to be the first to pick up an error if it is missed by the doctor or pharmacy. This must occur before the baby picks up the error. The nurse must have intense knowledge of every fluid, electrolye and medication given. Ongoing education is a must to stay sharp whether it is provided by the facility or the individuals care enough about their license to stay current.
I am not a fan of "mail-order" nursing schools that many paramedics choose because there are so many things that a student should be made aware of in their clinicals that can prevent medical errors or frustration later when trying to administer various meds by various routes. Even becoming familiar with the pill crushing and which pills crush and which don't go well with a G-tube play an important part no matter how boring it might seem to those who thrive on an adrenaline rush. There's nothing like have experienced people around when you are learning to point out some of the little things that can go wrong or how to make something go more right. Just having someone to point out similarities in packaging can make a big difference. Many times those experienced people may have learned something the hard way themselves. When paramedics don't think they "need all the floor nursing stuff in clinicals", they don't know what they don't know. Besides just the routine patient hygiene things, there are so many things you are not going to get in any book even a pharmacology text or the Nursing "Bibles" by Lippincott. On the job in the ICU/ED is not the time to be fumbling with the little quirks of medication administration. This applies also to the new paramedic graduate on the streets.
I posted this article earlier this year as an awareness for the number of things that can go very wrong for a patient anywhere in the healthcare system.
http://www.emsresponder.com/features/article.jsp?id=5774&siteSection=4
I have made a few medication errors myself over the years. Fortunately I have caught them just before delivery. The one exception I didn't catch was as an RRT. I gave Atrovent which is pretty routinely given everywhere along with Albuterol. I was in a hurry and did not check for glaucoma meds or history. Although it happens very rarely that it is narrow angle glaucoma, which still is not a good defense, the patient's eye sight was compromised for a few very long hours for both of us.
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JJR512
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I know that whenever I bring a patient into a nursing home, the actual nurse I need to report to is almost always working at a meds cart.
Ridryder911
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That is why there is usually a "med nurse": as well dependent upon the nursing model of activity, some may use this system on med surg units. As well as there is CMA (certified medication aide) that is certified to assist the licensed nurse in administering medications.
Again, some things are not as simple as they appear. That is why I don't go into a hissy when I do not get an immediate answer I ask at a nursing home. The CMA may never have seen any of the patients except to give meds. as well as the LVP/LPN may never give your patient any of their medications, so they can not immediately recall what they receive.
One has to remember as well, that sometimes in long term facility one licensed nurse may be responsible for 50 -100 patients at a time and the RN, may be technically responsible for all of them. Hence; why some of the problems we see can be understood, albeit it not right.
Yes, I still make them accountable, and get upset when inadequate care or poor care has been administered, but do understand their position and job. Usually, one gets what they pay for.. unfortunately, most geriatric patients get short changed.
R/r 911
Again, some things are not as simple as they appear. That is why I don't go into a hissy when I do not get an immediate answer I ask at a nursing home. The CMA may never have seen any of the patients except to give meds. as well as the LVP/LPN may never give your patient any of their medications, so they can not immediately recall what they receive.
One has to remember as well, that sometimes in long term facility one licensed nurse may be responsible for 50 -100 patients at a time and the RN, may be technically responsible for all of them. Hence; why some of the problems we see can be understood, albeit it not right.
Yes, I still make them accountable, and get upset when inadequate care or poor care has been administered, but do understand their position and job. Usually, one gets what they pay for.. unfortunately, most geriatric patients get short changed.
R/r 911
The pediatric nursing homes and subacutes are not much better. I used to do per diem as an RRT at a Pedi Subacute. There were 50 patients with the majority being trached and 20 of those on ventilators. The staff consisted of 1 RN, 1 RRT, 1 LVN and 2 CNAs. I also did diaphers and feed bags as well as the ventilators, trach care and respiratory assessments on all 50 patients.
Of course, the pedi NHs are better than the kids being stuck in the remote corner of an adult facility.
disassociative
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Does anyone remember the R's of medication administration?!?
Right Patient
Right Route
Right Dose
Right Time
It does not matter who hand's you a medication(RN, LPN, MD, DO,NP,EMT,EMT-I,EMT-P, etc). You ALWAYS double check
the R's of a medication before you even entertain the idea of even thinking about administering it. As evidenced by this situation, the one who administered the med is the one held liable. I am sure that everyone here knows this and more; however, I felt the need to state it--in case there is someone here that does not.
Right Patient
Right Route
Right Dose
Right Time
It does not matter who hand's you a medication(RN, LPN, MD, DO,NP,EMT,EMT-I,EMT-P, etc). You ALWAYS double check
the R's of a medication before you even entertain the idea of even thinking about administering it. As evidenced by this situation, the one who administered the med is the one held liable. I am sure that everyone here knows this and more; however, I felt the need to state it--in case there is someone here that does not.
TrmaGrl220
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whatever happened to the four R's ? Right Drug, Right Patient, Right Dose, Right Route. Dang nancy's.
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JJR512
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I was taught in EMT-B class about the five Rs. Curiously, all five of them were mentioned in the last two posts, although neither post had all five of them together.
Patient
Medication
Dose
Route
Time
Patient
Medication
Dose
Route
Time