Thursday, August 4, 2011

Would You Report Yourself for Making a Drug Related Mistake

June 27, 2011

As a registered nurse since 1976, the headline today was more than tragic, it was frightening. Human’s are and always will be prone to mistakes. It is impossible to believe that even if you are a physician, a nurse, or any part of the healthcare team, that mistakes will somehow be magically eradicated. The best way to prevent drug errors is by following the ten rules of mediation administration. Then, if in doubt, always have another peer double check your work.  Those ten rules of medication administration include the following: Right medication, Right Manner and Route, Right Patient, Right Time, Right Dosage, Right Documentation, Right Assessment, Right Evaluation, Right Education, Right of the Patient to Refuse the Medication.

 Easily said. Not as easily followed, especially in high risk units such as ICU (Intensive Care Unit) or NICU (Neonatal Intensive Care Unit).

The drug error that occurred on September 14, 2010 to an eight-month-old infant was a matter of drug miscalculation. The drug was Calcium Chloride, an essential electrolyte of the heart and may have been given to help the infant’s heart pump more effectively. However, if too much is given, it can cause irregular heartbeat, rapid heartbeat, or coma.

Although the article does not state what steps were taken to reverse the error of calcium chloride it may be that the physician and other healthcare workers would have used Magnesium Sulfate to try and counter the effects of the drug error made with calcium chloride. Magnesium Sulfate is listed as the antidote for calcium chloride.  It was not stated in the news account that the drug error was the actual cause of the infant’s demise five days after the error occurred.

Of more importance are the events that happened right after the drug error occurred. The registered nurse who made the error was Kimberly Hiatt and this drug error was the first one in her career of 25 years. As another point of importance is that Ms. Hiatt had received a 4 out of 5-point evaluation just two weeks prior to this drug miscalculation. Immediately upon administering the wrong amount of calcium chloride, Ms. Hiatt called out “Oh my God, I’ve given too much calcium!”  This is the reaction of an ethical person and a prudent nurse.  Ms. Hiatt took responsibility for her actions and set into motion all attempts to correct the situation.

What did the administrator and Director of Nursing do to correct the problem and prevent it from occurring again? They escorted MS. Hiatt RN out of the hospital, placed her on administrative leave and terminated her two weeks after the error. Seven months later, Ms. Hiatt hanged herself in her home.

If you were a new or a seasoned registered nurse what would your instincts be if YOU were to make a drug error?
barbara bethard



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