Despite a lethal medication mix-up causing the death last year of an 81-year-old man in the US, who died 48 hours after being given the wrong drugs, the nurse involved has not been disciplined “because of the multiple process failures” that reportedly happened outside her normal role.
The patient had been admitted to CHI Saint Joseph Health Main in Lexington because of a gastrointestinal bleed, but this didn’t cause his death, according to the coroner’s report, which instead, blamed a medication mix-up.
LEX18 reports that the coroner stated the patient died from “complications of inadvertent administration (Naturalyte) in the setting of gastrointestinal haemorrhage”.
The nursing board’s investigation described a series of events that led to the patient being mistakenly given Naturalyte, a dialysis liquid, instead of a colonoscopy prep called GoLytely.
‘Multiple process failures’
Nursing board executive director Kelly Jenkins told LEX18 that fatal medication errors are very rare.
“When you go back and look at all the steps, from the time they got the order to give the medication to the time it actually hit the patient, there were multiple process failures,” Jenkins said.
Another expert questioned why the Naturalyte, which isn’t made to be ingested, was available in the ICU.
A letter written to the nursing board by the nurse’s attorney states that the dialysis team had left the dialysis liquid behind on the ICU floor and it could have been there for up to three days.
As a safety precaution, nurses have to scan barcodes on patients’ wristbands and then scan the medication they’re about to administer to ensure that the correct patient gets the correct medication in the right dose, Jenkins said.
In this case, the dialysis liquid, considered the colonoscopy prep medication, would not scan. The nurse called the hospital pharmacy at about 5.35pm on 30 June 2022, and told them it would not scan.
Rather than sending new medication or going up to check, the pharmacy sent a label to the ICU floor through a tube system used to send and receive medication and supplies. This was sent about five minutes after the nurse called.
The nurse gave the patient about 240ml of the Naturalyte, believed to be GoLytely, before the end of her shift, her attorney said.
A timeline in the file notes that the patient was “unable to tolerate” the liquid.
The doctor who’d initially ordered that the patient be given colonoscopy prep said he had to take the full amount ordered, according to the timeline and attorney’s letter.
After the first nurse left for the evening, another staffer gave the patient the rest of the liquid through a feeding bag.
The medication mix-up was caught at about midnight, and the patient died at 7.35 the next morning.
The nurse had been caring for three ICU patients at the time of the incident – more patients than she usually would have been caring for as the charge nurse on the shift, according to the attorney’s letter, which added that three nurses had been pulled from the
ICU that shift to work on another unit.
When the patient who ultimately died was transferred to the hospital, she took him on as a third patient.
Because of the multiple process failures that reportedly happened outside her role, the nurse was not disciplined by the nursing board.
However, in a letter, the board voiced concern that she had not visually double-checked the medication’s label before administering it.
Technology
Ohio State University Wexner Medical Centre’s medication safety officer Joseph Melucci said technology and fail-safes are in place to help staff slow down and avoid mistakes like this one.
While technology is used to help prevent mistakes, it can also lead to a level of over-reliance and complacency, both Melucci and Jenkins said.
“There's nothing like the human mind to evaluate the state of circumstances when you’re about to do something that’s risky for a patient,” Melucci said.
In the Saint Joseph case, he said it appeared that a workaround was used when the barcode didn’t scan.
According to the nursing board’s investigative file, the nurse involved in the Saint Joseph incident later attended training on how to avoid medication errors after the incident.
Just weeks later, she was able to prevent another potentially fatal medication mix-up before that medication ever reached the patient.
The Kentucky Board of Pharmacy is still investigating the incident.
See more from MedicalBrief archives:
US former nurse convicted in lethal drug error sentenced to three years’ probation
Medical error and ‘chilling’ conviction of US nurse for criminally negligent homicide
NHS prescription errors contribute to 22,300 UK deaths a year