Sunday, June 18, 2006

Error

A few weeks ago a pregnant woman was killed by an overdose of magnesium sulfate at a hospital in south Florida. An 18 year old woman came in " seven months" pregnant in preterm labor. Magnesium sulfate, a drug commonly used to attempt to stop preterm labor, was ordered and given. Unfortunately, instead of getting 4 grams as ordered, the mother was given 16 grams. She developed cardiorespiratory arrest and died, in spite of resuscitation efforts. Doctors performed a caesarean section and delivered a live baby who is hospitalized in the NICU.

Hospital officials said the error was made by one nurse who simply gave an incorrect dose of magnesium sulfate. Like most people who read this story, I have tremendous sympathy for the family of that woman and child. But the person who I can't get off my mind is the nurse who gave the overdose, for whom my overwhelming emotion is also one of sympathy.

Like most doctors and nurses, I have made mistakes during my career. But I cannot recall making such an obvious error that so directly resulted in a patient's death. It is almost mind boggling to think of what must be going through that nurse's mind. How can she live with the knowledge that she caused a woman's death? Is she having suicidal thoughts? What defense mechanism can she employ to let her live with herself? She is apparently an experienced, excellent nurse. Anyone can make mistakes. Could that have been me making such an error? Am I a better health care provider than her, or just luckier?

My hospital has been participating in a perinatal safety project run by the Institute for Healthcare Improvement (IHI). The IHI would blame not so much the nurse here as the system or process. Every process that may result in danger to a patient, such as giving magnesium sulfate, should have some redundancy and safety checks built into it. Maybe more than one nurse needs to check the dose or IV rate; maybe there need to be maximums on how much magnesium sulfate can be put into one IV bag; maybe some other process change is needed. But safeguards are needed for everything in medicine, to prevent the one time in a hundred or a thousand that someone makes a potentially deadly mistake - not only for the health of patients, but also for the emotional health of medical workers.

P.S. Pediatric Grand Rounds is up at Unintelligent Design.

12 Comments:

Blogger Fat Doctor said...

You are merely luckier, as am I, thank God.

5:20 PM  
Anonymous NurseEm said...

In Australia, every IV drug has to be checked by two RNs before hanging. That is not to say that mistakes don't happen, but it is one way to minimise them. I am an RN student graduating at the end of the year, and it frightens me to think I could make a mistake like that.

8:17 PM  
Blogger NeoNurseChic said...

:( That's very sad... I've never given Mag Sulfate to know how it is mixed and given. The only meds we mix ourselves are things like ampicillin or drawing up correct doses of lasix, morphine, versed, synthroid, etc. If someone was orded a continuous mag infusion, the med would come up from the pharmacy with the specific amount in the bag - not 4 times what is supposed to be given. Unless that is, the order is written incorrectly - and then the pharmacy checks are supposed to catch that. These types of errors really are a system thing, even though the nurse who made the error probably is in a really bad place right now with herself. She was ultimately the last checkpoint in the system... I cannot even imagine - actually, I can imagine how I would feel if that were me that was the mother's nurse, and it would not be pretty... We have to cosign all electrolyte riders now (although some people don't since this is a new thing) and our hospital (or most hospitals, I think) does not allow meds like KCl to be mixed on the units - has to be obtained directly from the pharmacy. Too many people were given undiluted injections of Potassium, resulting in a lethal injection.

A friend of mine did recently set a pump to infuse intralipids 20% over an hour instead of over 15 hours. The babies liver function was fine, thank goodness. Now every time I hang my lipids, I check the pump about 50 times. Could be any one of us, which is the scary thing! I guess, if you think of it that way, the baby did get 15 times his dose of IL, but not 15 times his total dose - just 15 times the dose in the hour. I'm wondering if the Mag Sulfate was sent up with the correct amount, but run 4 times too fast - or if the incorrect amount was sent up or mixed altogether... It could be just as deadly to run a med like Mag 4 times too fast as it would be to give 4 times as much.

One of my former nursing professors is big into studying med errors. One time as she was lecturing, I made a list of all the med errors that had occurred just to ME in the span of about 7 hospital stays - and these were only errors that I specifically knew about. One of the worst was actually a near miss in that in the note from my neuro's office that went in the front of my chart, it had a list of meds I'd taken previously. One of the residents entered nortriptyline into the system as a med I was supposed to be receiving, even though I'd been off it for quite some time. I was on parnate at the time for headache prevention, and as you know...MAOIs and TCAs can be a deadly mix... Somehow, the pharmacy didn't catch the interaction either. And then, a new nurse was orienting with a nurse I was very familiar with. The new nurse brought in the nortriptyline and handed me the pill without telling me what it was. I asked her what it was, and then she told me. I then proceded to have to argue with her for the next 5 minutes about why I couldn't take the med. She kept saying to me, "Well they ordered it for you." She wanted me to just take it since obviously the doctor was right in ordering it, and I was just being the obnoxious patient. She finally relented, and I called her preceptor in the room and told her that I didn't want to get the other nurse in trouble, especially since I knew that she was new, but explained what had happened. Thank God I wasn't lethargic and didn't just take the med without even questioning what it was... That could have very easily been the case as I usually am asleep most of the first 3 days of the hospital stay from the very strong mix of meds they use.

Lives are fragile - we can never believe that we are immune from making med errors or that we are too good for that. Because the moment anyone gets that comfortable, mistakes happen and lives can be lost. Not a day goes by where I don't think about that before I give meds to babies.

Take care,
Carrie :)

8:31 PM  
Blogger Megan said...

my heart goes out to her. FD is right, we are merely luckier.

10:57 PM  
Blogger stockingup99 said...

Another point for the home birth crowd. Without drugs and knives available, they can't be used.

How 'bout when I reminded the doctor that he agreed I could tear, and he continued to cut an episiotomy over my objections? Was that a medical error? If the scapel hadn't been handy, he wouldn't have used it.

The routine interventive managed delivery is frought with peril. Thank you Neonatal Doc for picking up the pieces.

8:22 AM  
Blogger Flea said...

Nothing original to add here.

Another lucky (sort of) flea,

Flea

10:00 AM  
Anonymous Dianne said...

I agree with you entirely. By the sound of it, the nurse involved made a minor mistake. If that sort of mistake can cause a fatal outcome then there is something badly wrong with the system. Blaming the nurse who gave the mag sulfate won't keep the same sort of error from happening again. Adding safeguards might.

It's always tempting to blame the threat of malpractice for everything that goes wrong in medicine, but I do wonder...If people weren't so afraid of getting sued if they admit to error, might it be easier to catch error-prone procedures before they lead to fatalities? If something like the IHI you describe had been in place and personnel were encouraged to report errors they made or witnessed, the IHI might have noted that, say, one error occurs for one in every N meds given and sought a way to lower N before a dramatically bad outcome such as this occurred. Then the fatal outcome might never have occurred because the necessary correction would have already been made. But for that to be possible, people would have to be allowed to admit to mistakes without fear of being punished for them and I don't see that in the current social climate.

10:27 AM  
Blogger Ex Utero said...

I always caution housestaff that we never give potassium as a push or a bolus (always as a "rider" or "slow infusion") because I'm trying to teach them to think about the way they give that particularly dangerous ion (because it can transiently prevent repolarization of the heart and cause it to stop beating - especially in a neonate where the volume of distribution is so small).

We hold something very fragile in our hands when we write out an order and I'm not talking about an ink pen. The magnessium story is terrifying, particularly so because I consider that to be a relatively safe drug. I wonder if she was in over-worked and under-staffed conditions?

4:08 PM  
Blogger NeoNurseChic said...

Reminds me of something I think about every day:

There, but for the grace of God, go I.

11:56 AM  
Anonymous Shamhat said...

Magnesium sulfate comes in premixed IV bags, 40g/1 liter or 20g/500 ml.

The typical order would be a loading dose of 4 g in 30 minutes (100 ml/30 minutes) and then 2 g/ hour (50ml/hr), to be adjusted based on magnesium levels drawn every 6 hours.

At the same time, the mainline of LR would also be put on a pump and the rate adjusted to limit fluid intake to 125 ml/hr (output is also measured).

My guess would be that when the nurse set the loading dose, instead of programming the pump for a rate of 200ml/hour with a volume of 100 ml, causing it to stop and wait for re-programming when the loading dose finished, maybe s/he programmed it for 200 ml/hour with the volume of 1000 ml, which is actually what's hanging, intending to stop it manually after 30 minutes and reset it.

5:34 PM  
Blogger neonataldoc said...

Thanks, everyone. Dianne, you bring up an interesting point about the effect of malpractice suits. You're right, we're afraid to admit it when we make an error. And Carrie, your story points out that the best guard against error when you're a patient is yourself.

8:25 PM  
Blogger NeoNurseChic said...

Supposedly, our hospital does not punish or retaliate against personnel that make mistakes. But, I also have my own malpractice insurance separate from the blanket covered by the hospital. I have been told that if I deviate from any one of the thousands of hospital-specific procedures, then they don't have to cover me. That scares me, so I got my own insurance. One can never be too careful...

That being said, I don't see that it makes anyone less afraid to report mistakes. I guess that our entire upbringing is based on the fact that we must hide anything we've done wrong from our superiors, be they parents, bosses, etc. It is a nervewracking society.

I must say that from the patient perspective, I've had a lot of things happen to me that make me think I should have renamed myself "Murphy" a long time ago. However, I've never sued or threatened lawsuit. One thing that happened last year made me so angry that I tried to get a new neurologist, but my neurologist refused to let me switch to a different doctor in the same practice, and I would have had to travel to other states to find the same level of specialty if I had to change offices. The one thing he did that really pissed me off was constantly pass blame on to everyone but himself - including blaming me. I won't get into the entire situation, but I had contacted him 3 times in 1 week about a medication that ultimately left me in the ER unresponsive one night. What would have alleviated all of my anger and negativity about the whole thing, would have been an acknowledgement of some responsibility on his part for not listening to me. Instead, when I said I felt that he hadn't listened to my concerns about how I felt on the med, he told me that maybe I was "too angry to continue treatment there and would be better off seeing Dr. such-and-such in Michigan." It took a long time for me to get over that.

As bad as our environment is with lawsuits and the like, I still believe that most people will settle down with some sort of apology or acceptance of responsibility. Some will sue anyways, and that's the chance we take. I wouldn't go out of my way to apologize for something that the patient would never have known about and would not do them any harm whatsoever, but once it's out in the open, I have apologized for things before and been met with very receptive feelings. We are all human and we all make mistakes.

I hate that the threat of lawsuit makes people so afraid to step up and report or own up to errors. Like I said, I've been on the receiving end of some major doozies, and I've never sued. I've been inclined to on a couple of occasions because the entire situation was handled TERRIBLY. But then, being a nurse and a patient puts me in a more unique position that I can understand the perspective from a couple of different angles without having to try so hard...

Take care,
Carrie

P.S. ND - you're totally right about the patient being the last line of defense. Unless of course, the patient is a neonate or in the OR or unable to speak for his or herself or, in the case of Mag Sulfate, wouldn't know the dose was wrong, etc. When I was a student, if an adult ever questioned a pill I was giving them, I took it right out of the room and consulted with other nurses, pharmacy, physician, etc. I would never push a med on a patient that questioned whether or not they should be receiving it. I still count my blessings for having questioned that med...

1:39 AM  

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