Wednesday, December 13, 2006

(Almost) Unbelievable

On Nove 3rd, an ARTICLE about a med error was printed in the Wisconsin State Journal:

Nursing and hospital officials were outraged Thursday after the state filed a felony charge against the nurse whose medication error caused the death of a teenager at St. Mary's Hospital in July.

It's the first time a health- care worker has been criminally charged for an unintentional error in Wisconsin, the officials said. They said the filing could make it more difficult to recruit and retain nurses, already in short supply...She mistakenly gave Gant an epidural anesthetic intravenously, a state investigation previously revealed. Gant was supposed to receive penicillin through the IV for a strep infection. An epidural is supposed to be injected near the spine to numb the pelvic area during birth



Wow. I began to think about how possible it would be for this kind of med error to happen- I was trying to go through the steps in my head, but further down, the article provided all the steps she had to take in order for this to happen:


Improperly removed the epidural bag from a locked storage system. Gant's physician, Dr. Joseph Fok, never ordered the epidural.

Didn't scan the bar code on the epidural bag, which would have told her it was the wrong drug.

Ignored a bright pink label on the bag that said in bold letters, "FOR EPIDURAL ADMINISTRATION ONLY."

Disregarded hospital and nursing rules in failing to confirm a patient's "five rights" when receiving drugs: right patient, right route, right dose, right time and right medication.


Of course that made me think, OK she really screwed up. But also, I was trying to imagine myself in her situation (which is always hard to do, because you never really can) and I thought about of all of the little things that happen during a shift-almost absentmindedly. I still don't know how she missed this...it seems so glaring, but who am I to say? Do I have any say, as a future nurse? IF I were called to testify, would I stand up for her, my fellow nurse? I was still torn...but then I read this statement from the nurse:



I allow priority for compassion to override the need for detail.


Notice the present tense "allow" not "allowed" as in past tense mistake, but present tense. I was no longer torn. Maybe it's me, but when I'm the patient, please spare me the compassion if it comes at the price of my life.

I hope you all read the article for yourself, but in the case that you don't, the 16 year old girl died from the injection. The nurse "if convicted, faces a $25,000 fine and up to three years in prison and three years of extended supervision.

Seriously? Supervision...as in she'd still be working as a nurse? I don't think that should be an option. What do you think?

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