Saturday, September 23, 2006

Big Mistake

What are the three lies? Click here to refresh your memory:

For this entry, we'll stick with the clean ones:
I'm from the government and I'm here to help.
I gave at the office.
The check is in the mail.

To those, how about adding: It's just a shot; it won't kill you.

You probably heard the story -- three babies died because they got the adult dose of a blood thinner instead of the baby dose.  Here's the first couple of paragraphs in the story posted on AOL:

Fatal Drug Mix-Up Exposes Hospital Flaws

INDIANAPOLIS (Sept. 23) - Early last Saturday, nurses at an Indianapolis hospital went to the drug cabinet in the newborn intensive care unit to get blood-thinner for several premature babies.

The nurses didn't realize a pharmacy technician had mistakenly stocked the cabinet with vials containing a dose 1,000 times stronger than what the babies were supposed to receive. And they apparently didn't notice that the label said "heparin," not "hep-lock," and that it was dark blue instead of baby blue.

"The nurses didn't realize. . ." because they didn't take the time to check. They ASSUMED something, without confirming their assumption. They trusted the pharmacy tech. Big mistake.

A pharmacy tech, one of those jobs you can get from those schools that advertise on TV, is not going to be a genius. Why he or she is allowed to restock medicines that can kill people without having some kind of supervision is beyond me. 

Why the nurses aren't required to double check the medications the tech leaves for them is also beyond me. There should be a rigorous protocol for confirming medications. Check the label, check the dose, sign off with a supervisor.

I thought the writer was rather restrained in his observation that the labels not only have different names, but they have different shades of blue. That's two red flags they should have noticed.

Frankly, I think the manufacturer was a little casual with their labeling and product forms.

First of all, don't have names that are so similar. Heparin and Hep-Lock look too much alike for our reading challenged workers these days. Make them different so there wouldn't be confusion.

Second, print NOT FOR INFANTS in large letters along with ADULTS ONLY, too.  So there wouldn't be confusion.

Third, coloring one blood thinner blue and the other SOMETHING ELSE might have saved three little kids. At least prevented confusion.

Third, putting the baby version in a much smaller vial would have put up a red flag, too.  And prevented confusion.

I don't work in a hospital and even I could come up with solutions to prevent future mistakes. Don't the hospitals and phramaceutical companies already have people who do stuff like this?

I understand that the families are suing Abbott Labs for not labeling the two products in such a way that ANYBODY could tell the difference.

Blaming the manufacturer for not fixing the problem reminds me of when we switched to cash registers that can tell the cashier what the change should be, because most cashiers aren't smart enough to learn how to make change. The education and intelligence of our workers is so poor the machines have to do their thinking for them.

So far we don't have the equivalent of the cash register that figures out the change in our hospitals. The people who are dispensing drugs that can kill you have to be accountable on some level. Job loss is probably all they'll get. I know I wouldn't want any of those nurses or that tech working in my hospital. Of course, they probably belong to a union so they may just get slap on the wrist and a stern warning.

Despite their mistakes, they don't have money to pay for the pain and suffering the parents are going through.

And the drug companies do.


childebrand1968 said...

Living in Indy, I can say that his hospital is one of the best in the city, and I dare say these types of incidents are few and far between... though they are very negligent in the case of these babies.

It is a rule to always double check medicines before dosing... but like with most jobs, people get in a routine and take things for granted.

The nurses trusted that the vials were the right ones.  Mistake, no doubt.  But I think the  tech(s) who stocked the carts should get the most severe punishment.  I think the nurses should be reprimanded and made to go to some refresher classes or similar...  Mostly likey, they will all be fired.  

I agree that the manufacturer should change the caps to different colors entirely, rather than different shades of the same one... and that they should be held financially responsible, at least partially... though I doubt that will happen.


childebrand1968 said...

FYI~ No unions in hospitals here.  Well, not public ones anyway...


lanurseprn said...

Being an RN, I can tell you that there are always a lot of stops and checks that have to fall into place before a medicine reaches the patient.  The last one, however, is the person administering the drug.  I can't tell you how many times I've received the wrong drug, or dose from the pharmacy.  It falls to the person who ultimately administers the drug.  The hospitals try to create checks and balances. They do work, to a point.  But, it ultimately falls to the person who is actually giving the drug.  Simple as that.  Being an RN, I don't personally think there is ANY excuse for that kind of negligence.  NONE.  But, that's just MY opinion.

screaminremo303 said...

I just returned from a call for service involving a teenage boy who tried to un-jam his bicycle chain with his finger. While was riding the bike. While he was pedaling. Twelve stitches later I now understand why we need stickers and warnings on things. HUMANS ARE STUPID, LAZY ANIMALS.

sdoscher458 said...

I knew from an early age just how stupid people can be. I was eight years old in the hospital to have my tonsils out, the kid next to me was a BOY scheduled for some kind of stomach surgery.  They picked me up and put me on a gurney took me all the way to the operating room, before someone noticed - oh this is a girl, not a boy...oh crap we have the wrong patient! The orderly took me back, he was angry and dumped me on the bed as if it were my fault that he was so stupid not to read the charts right.  I hope those parent sue the doctors/nurses/hospital and anybody else who was involved. Sandi

rebuketheworld said...

It was a sad story but humans are flawed....I'm sure these nurses will grieve. Something like light blue vs. dark blue font and words so similar,,,its something that can just easily happen....Its all so sad....I'm sure the hospital will turn itself upside down trying to resolve this from never happening again but in this case, its not the same as a doctor cutting off the wrong breast. Details,,attention to details every single day and moment at work is bound to find mistakes...I'm just amazed how doctors and nurses do this all day long and this rarely happens..I think doctores and nurses extend perfection to the furthest degree of what is possible for man....

sad for everyone involved...-Raven

jevanslink said...

Interesting that you say the FONT was a different shade of blue.  I went back and reread the sentence and , technically, grammatically, IT refers to the FONT, not the color of the product itself.    

That's even worse.  Perhaps if the adult version was a colorless liquid and the kids' version was blue it would have helped.  But it both were colorless, sheesh.

Mrs. L

suzypwr said...

The pharmacy tried to hand me a prescription once that I knew wasn't mine. They said it had my name on it, so it had to be mine. I refused it. I went back to my office and called my ex, the pharmacist, and told him what the rx was. He said I should have taken it. It lowers blood pressure, and mine is so low naturally that I have to have a warning on my driver's license. He said I could have paid off my house from that lawsuit, had I chosen to accept the drug.

Another time, I was in a hospital the day after major surgery. I was groggy, but not stupid. A nurse came to me with a pill in her pocket, loose, and told me to take it. I didn't recognize it, and said NO. She got mad, I got mad, and I still said NO. She came back to me later, and apologized. She said it was for the man in the next room. I asked her what it was for. What else? To lower blood pressure. Even with my entire abdomen full of stitches, I laughed. No, I didn't even bother to make a complaint, although I should have.


mombzbe said...

In my line of work, we have to double, triple, quadruple check things all along the way.
I'm meticulous, I'm careful, and still, have caught myself writing XX when I see XY; and while no harm, no foul happened, I still shudder when I think about making the mistake.

People get hurried, they get complacent, and there's no excuse; no exception--no one is perfect.  But if you are working with life or death, you should be.