Endangering the patient . . .

Earlier this month a medication error was reported at Cedars-Sinai Hospital. The television show “TMZ” (The Thirty Mile Zone) first broke the news of this error, since it involved the children of a celebrity. The error, as it was reported, involved the unintentional overdosing of three infants (though other sources have reported that the incident may have involved up to 13 infants) with a Heparin overdose. Two of the infants that were affected by this medication error are the twin infants of Dennis Quaid and wife Kimberly Buffington.

As of today, Nov. 25, 2007, there seems to be several conflicting stories, so I’ll start with the initial report. TMZ broke the news with the following general information; three infants received inadvertent overdoses of Heparin, used to flush IV lines. They reported that two separate doses of 10,000 u were administered: the first was on Saturday and the second 10,000 u was on Sunday; and that the error was caught when the nurses noticed that the infants were beginning to “bleed-out”. The drug Protamine, the anti-dote to the Heparin overdose, was administered and the children were in Neonatal intensive care (NICU). Cedars later issued a press release that characterized the incident as an error that occurred due to a technician inadvertently placing the high concentration 10,000 u vial of Heparin (usually used in adults only) in the unit’s pharmacy stock, the nurse accustomed to only one dosage type (the lower concentration vial of 10 u) being available grabbed the high concentration vial and administered the incorrect amount, the nurses realized an error had occurred, ran the test to confirm their suspicions and then administered the anti-dote, Protamine. The hospital admitted that the error occurred in part because the nurse did not follow hospital protocols and procedures and that the State of California Department of Health and Human Services was investigating the incident. It has also been reported that the infants were in stable condition and had suffered no ill effects.

In my opinion the most interesting coverage about this unfortunate, but preventable, error came courtesy of the Los Angeles Times. Their coverage appears to me to be an almost “kid glove” handling of this very serious medication error and breech of nursing practice. Let’s not forget that Cedars is suppose to be a “Best of the Best Hospital” and a Magnet Hospital and the list of so-called “excellent” hospital awards goes on, so for such a medication error to occur should have news agencies asking the tough questions. Instead, news agencies seem to be happy to regurgitate the Cedars press release and to “downplay” the incident by spinning it as medications errors in hospitals are not uncommon. When a similar incident occurred at the now defunct King/Drew Medical Center several years ago the LA Times, rightly so, reported heavily on the hospital’s failure to safeguard their patients from medication errors; but they seem unwilling to use the same journalistic scrutiny on Cedars during this incident. The first Los Angeles Times’ article, which ran the day after the story broke on TMZ seemed to be mostly a regurgitation of the information provided by the Quaid/Buffington family, TMZ and the Cedars-Sinai Hospital authorized press release with no real new information provided. The second story, which ran the next day, in the Los Angeles Times tried to convince its readers that hospital drug errors were not uncommon; and if we believe this then we should be very concerned about the state of nursing and medicine in our Nation’s hospitals. What the Los Angeles Times failed to mention or question was how could such a medication error and failure of basic nursing practice occur in a hospital that proudly displays its US News America’s Best Hospital 2007 award and that it has been awarded the American Nurses Credentialing Center’s (ANCC) Magnet Excellence in Nursing status. Cedars even proudly displays this statement from the ANCC on its website “The ANCC found that Cedars-Sinai's nursing services "represent the highest standards in the nation and internationally." I would have to say that the recent Heparin overdose incident puts this label into question. But then again most RNs think that both Joint Commission and Magnet status are “jokes” and more often representative of how well hospitals prepare and present their documentation and how they “play” to their surveyors then an actual representation as to the quality of care and the nursing staff.

As a RN with over 35 year of experience at both the bedside and in nursing management and education I find the nursing error at Cedars frightening, but not completely surprising. Why, because I am very familiar with this particular hospital and the caliber of its nursing staff. And though there are many good nurses at Cedars, I also know that the nursing staff as a whole has not always been at the peak of their game (also using many registry and traveler RNs). The past several years have seen at least two, ugly, but failed unionization attempts of the nursing staff. These attempts have taken their toll on the staff and have left many nurses feeling angry and betrayed by one or the other side. I know that at least one unit, which once had a very stable staff, has experienced a great deal of turn-over recently, and this turn-over has left the remaining staff feeling unsupported by nursing management, and in many cases feeling demoralized and burnt-out.

As recently as four weeks ago, a neighbor and nurse, was admitted at Cedars for surgery and when she returned she spoke of a very poorly run nursing staff and a care-environment that was anything but caring. What gave her great concern was the lack of English exhibited by the nurses in the clinical setting. She said during her entire stay that she very seldom heard a word of English spoken in her presence (she is an English speaker) and she was concerned that if their English was so poor that they had to communicate to one another in their common “native” language then how well did they comprehend orders that were given in both verbally and in writing in English.

However, as a RN, what concerns me greatly is the failure of the nurse to follow the most basic of nursing protocols and that is to always check the medication (and that means reading the label). We work in a field that is not only high-stress but prone to human error and it is for this reason we are taught to rely on our eyes to verify such things as: is it the right medication, the right dosage, etc. The excuse given that “the nurse was unaccustomed to more than one type of heparin vial” is a poor one.

This past April I covered the issue of medication errors for my column From the Floor, which is published every three weeks in Working Nurse Magazine. My article can be found by following this link http://www.solutionsoutsidethebox.net/articles___studies. In this article I spoke of a medication error that cost a young mother her life and left her newborn an orphan and how medication errors occur and what nursing and hospitals can do to minimize and reduce situations that give rise to errors of this magnitude. There is a current trend in nursing and medicine to practice what has been labeled “blameless medication errors” the premise of this method is that if we do not “blame the nurse” for a error then the nurse will be more forthcoming when an error occurs thus allowing the error to be addressed and a correction plan implemented. However, the downside to “blameless medication error” reporting is that there may very well be an incident in which protocols and practices have been violated in such a way that blame should be assigned, as in the case of outright negligence.

What concerns me about the Heparin incident at Cedars is that 1.) This is not the first time this type of error has occurred, 2.) There was an FDA warning issued about the possibilities of such incidents, 3.) No one double-checked the vial to ensure it was the right medication or dose, 4.) The conflicting reports that first there were two overdoses versus just the one, 5.) First reports provided different facts as to how the overdose was caught, 6.) Reports seem to vary greatly as to how many infants were actually given the Heparin overdose and 7.) The report that there have been no ill-affects, when any NICU nurse or physician knows that it could be weeks to months before we learn if the children who received the overdoses will suffer from any negative sequelae.

Yes, this was indeed a culmination of a series of human errors, however as nurses one of our jobs is to serve as the patient advocate, which sometimes translates into the last line of defense. In the end there should have been two nurses whose job it was to ensure that the patient received the correct medication and dosage. The nurse whose job was to administer the medication should have had another nurse check the order, the vial for appropriate drug and dosage (it was never stated if another nurse had check the dosage and drug). This failure to practice what is a most basic of nursing skills has caused several infant lives to be endangered, families to be traumatized; and for the nurses and the staff involved this may very well be a career ending event. Let’s hope that this time we learn the lesson so that no other infant is placed in this type of preventable medical jeopardy – again!