Tag Archives: medication error

Life imitates art

Life imitates art

One of the shows that I like to watch is “Criminal Minds”. In season 9 episode 24, “Demons” there is a scene where Spencer, one of the FBI agents, is in the hospital after being shot. The un-sub wants Spencer bumped off and sends a nurse in to administer a medication to Spencer that he is highly allergic to with the intention of killing Spencer. This was prevented largely because it was in the script… ;] OK, it was thwarted by both Spencer and Garcia having kept track of all the medications that had been given to Spencer along with the times and reasons.

While this is just a story, medication errors can and do happen AND can have fatal results.

Most of the time being in the hospital ends with good and expected results. However it is wisest to have a friend or family stay with your loved one 24/7 while they are in the hospital [and at medical appointments too]. As the patient and sitter, it is prudent to know what medication and treatments are ordered and why it is being ordered. Keep a record of all medications you [the patient] are given along with the time and who gave it. Yes the staff will be doing that too, the reason for keeping your own records is so that you can keep track in your own head and can ask questions if it seems appropriate. Another thing is that you should always get to know your care providers on a first name basis and about their background. This serves the purpose of general getting to know each other like most humans. It also makes you more human to your care providers. So instead of the gallbladder in room 5003, you are Sam Jones in room 5003 who had his gallbladder removed.

Most medication errors are the result of understaffing and over work. Another major contributing factor is when regular staff get ‘floated’ into another specialty area from their own. This floating is generally not something the staff likes to do because they know that they are less proficient in the area they go to. Part of the dislike of floating is that they could have already worked a few hours someplace else.

Sometimes the cause of medications errors is that the patient is complicated by many health issues. As an example let us say that the patient is pregnant with twins and develops a DVT [deep vein thrombosis] aka a blood clot, in this case of the leg. Being pregnant and high risk [twins and the DVT] she was placed on the OB floor. OB does not deal often with DVTs and Heparin. DVTs and heparin is mostly dealt with on medical floors or heart floors. So in a case like this the staff was not familiar with this medication and procedure.

A common treatment for this condition –DVT- is bed rest and blood thinners [Coumadin or in this case Heparin IV] even if the heparin is administered via an IV pump which is intended to very precisely give the ordered amount of medication over a specified time period. Sometimes the pump glitches and runs the medication in too fast which is not good. This happens often enough that as a safety tool we calculate how much fluid should be infused. The route is the bag of IV fluid with the ordered concentration of Heparin is hung on the IV pole, next is the Buretrol and then the pump into the patient. This calculated amount is placed in a Buretrol from the main bag, the feed from the main bag is clamped off to prevent more medication from going in. In this hypothetical case the clamp between the main bag and the Buretrol was not engaged which let the medication overload and could have harmed or killed the patient. By the way, the active agent in Rat Poison is – you got it, Coumadin.

While you are talking with the staff find out how many other patients your care provider has, what floor they normally work, how many hours they have already worked along with how many shifts they have worked in the last week. While you are at it ask them how often they have dealt with the medication and conditions in your case.

Survival concerns are common EVERY day we live.

Remember, we have to prepare to survive and thrive, every day.