In 2017, a Tennessee hospital nurse gave a patient the wrong medicine, administering a strong paralytic drug rather than an anti-anxiety drug. The patient died as a result. A patient safety organization recently announced that such medication errors are avoidable and detailed how all hospitals can prevent them.
The Anesthesia Patient Safety Foundation released a safety advisory following the organization’s review of the Tennessee hospital fatal medication error that has received widespread media attention.
In releasing the recommendations, APSF said one of its goals is to urge hospitals to take steps to prevent all medical errors, including medication errors. It also stressed that the medication error made in the Tennessee hospital is not an isolated incident.
Clearly Mark Powerful Drugs to Avoid Administration Errors
One APSF recommendation is for hospitals to clearly mark powerful drugs so they are not mistaken for lesser medications. In the Tennessee case, the patient incorrectly received a powerful sedative normally used during surgery. The patient was supposed to be given a much weaker drug to reduce her anxiety before undergoing a CT-scan.
Reportedly the nurse typed in the first two letters of the proper medication but the computerized medicine dispensing cabinet – designed to prevent medication errors – suggested the wrong medication. The nurse was using the drug’s brand name while the medicine cabinet stores drugs under their generic names.
She grabbed the more powerful medication without noticing it was the wrong drug.
APSF suggests that wrapping dangerous drugs in plastic and using brightly colored labels and large wording can help prevent similar catastrophic medication errors.
Overriding Electronic Drug Dispensing Cabinet Safety Measures
Another error the Tennessee nurse committed was using override to access the wrong drug from the electronic dispensing cabinet. These cabinets typically lock up powerful sedatives. She did a manual workaround to unlock the medication.
APSF recommends that hospitals not normalize these workarounds. Overriding electronic medication cabinets to access potentially dangerous drugs, even in emergencies, should be kept to a minimum. The Tennessee nurse had said such workarounds were common hospital practice.
Ineffective Hospital Culture of Safety
A hospital’s culture of safety can help prevent serious medical errors. In its 2022 “Preoperative Patient Safety Priorities,” APSF has “Culture of Safety” at the top of the list.
According to ASPF, a proper hospital culture of safety should include promoting the reporting of medication errors so that hospital staff can learn from them and develop appropriate steps to prevent them going forward.
Other APSF recommendations to avoid serious medication errors in hospitals include:
- Using pre-filled medication syringes
- Using identifying barcodes on medication packages that must be scanned at the computerized dispensing cabinets
Medication errors are not rare. And when a patient is a victim of substandard medical care and preventable drug administration mistakes are made, a medication error can be fatal.
If you believe a member of your family was the victim of a medication mistake or any other type of avoidable medical error, discuss your case with a personal injury lawyer who has experience investigating medical malpractice claims.
The choice of a lawyer is an important decision that should not be based solely on advertisements.
Authored by Gray Ritter Graham. Posted in Blog June 14, 2022.
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