Another Deadly Med Error
Last summer, an 81-year-old man admitted to a Lexington, Kentucky hospital and died within 48 hours later. He had a GI bleed in which he was ordered GoLytely which is a bowel prep for colonoscopy but instead, the nurse gave Naturalyte, a dialysis liquid not intended for human consumption.
According to the Kentucky Board of Nursing, no charges were filed against the nurse for this medication error. In addition, I do not believe criminal charges were filed either. The Board, believing many process failures and system issues were involved, did not feel that charges against license of the nurse were warranted.
After treating another patient several days earlier, the dialysis team left the liquid behind on the ICU floor.
Nurses scan barcodes on patients’ wrist bands and then scan the medication they are about to administer. Unfortunately, the container of Naturalyte would not scan and when the nurse called the pharmacy, rather than sending the proper medication or coming up to see the liquid in question, the pharmacy just sent a label to the ICU floor through the hospital’s pneumatic tube system.
The nurse administered eight ounces of Naturalyte which she believed to be GoLytely before her shift ended. The patient was unable to tolerate the liquid and after the nurse left for the evening, a second nurse gave the patient the remainder of the bottle’s liquid through a feeding tube. The medication mix up was caught at about midnight, but the patient died the next morning.
This is so sad. That night, while the patient was being transferred to their hospital, 3 ICU nurses were pulled to work on another unit that night. The nurse who took care of this patient took him on as her third patient.
It is unfortunate that this terrible mistake was made and that the Barcode system wasn’t working which contributed to the nurse failing to scan the liquid to be alerted to the use of the wrong medication. The nurse should have done her Five Rights and known it was the wrong medication.
It’s interesting how one state north of Tennessee views things completely differently as in the Radonda Vaught case. The nurses involved in this Kentucky death did not face criminal charges or have trouble with the Nursing board. It would be nice if there was some consistency with neighboring states, if not the entire country.
So, I’m somewhat relieved that the nurses in the Kentucky medical error matter did not get charged criminally or face a challenge to their nursing licensing. That does not negate the loss.
