It Could Have Happened to Anyone
The phone rings at 2 a.m., and Judy is immediately awakened from her sleep. As she listens to the voice on the other end, she suddenly feels sickened with the news. The assistant manager of the unit informs her that a patient has been given a large dose of insulin that was intended for a different patient. The nurse failed to check the receiving patient’s armband or call the patient by name prior to administering the insulin. Because it was in the middle of the night, the patient was groggy and did not question why he was receiving medication. Now the patient was in severe hypoglycemia, hypotensive, and exhibiting cardiac arrhythmias. The patient was transferred to the intensive care unit, and the family was called and informed of the error. The assistant manager reported that the nurse was one of the more senior and experienced nurses who had an impeccable work ethic and a reputation for being one of the best nurses on the unit. She shared that the nurse was absolutely devastated about the error and nearly hysterical. The patient’s physician was very angry on the phone when the error was reported to him, and he was on his way to the hospital. Judy told the assistant manager that she would come to the hospital right away to meet with the patient’s family, physician, and the nurse. Before she left home, Judy phoned the department director, who also indicated that he would come in to the hospital to assist in any way possible.
When Judy arrived at the hospital, she was informed that the patient had just expired and that his family was on their way to the hospital. The patient’s physician was in the ICU talking with the other physicians and nurses who tried to resuscitate the patient. The ICU physician indicated that although the overdose of insulin contributed to the death, the patient’s underlying condition made it impossible to correct the hypoglycemia and to save the patient.
After speaking to the physicians, Judy went to her own unit to speak with the nurse who made the medication error. She could only imagine how devastated the nurse was feeling, so she approached her gently and with compassion in her voice and mannerisms. Judy listened to the nurse as she tearfully recounted the story of going into the patient’s room and administering the medication. She acknowledged that she had not checked the patient’s armband because she did not want to disturb the patient, who was sleeping. This was her first night to care for the patient who received the insulin and the patient next door who was supposed to receive the insulin. Both of the patients were men in their 70s who had the same diagnosis and who actually had similar physical characteristics and facial features. Both men had been admitted during the day and were assigned to adjacent rooms. To make matters worse their last names were similar. The nurse could hardly speak for the tears, and she was shaking uncontrollably. The assistant manager completed the forms necessary to report the incident to the hospital’s quality and risk management departments. After the nurse signed the documentation, Judy suggested that she ask a family member to come and drive her home. Judy was concerned for the nurse’s safety because she was completely distraught. She told her that it would be necessary for her to take several administrative days off, but she should be available to speak with the hospital attorneys and risk management.
After leaving the nurse, Judy went back to the ICU to meet with the patient’s family. When she arrived there, the department director was already engaged with the family, who were both angry and devastated with the news of how the patient had been given the wrong medication inadvertently and had expired. Because the department director and social services were working with the family, Judy returned to her unit to meet with her staff and the assistant manager.
Everybody on the unit was affected by the event, and many of the nurses were in tears. The assistant manager was also feeling the pressure of the situation and was trying to coordinate the care of the remaining patients on the unit. After working to stabilize the emotions on the unit, Judy met with the department director, the CNO, the physicians, and the attorney for risk management. The required phone calls and paperwork were completed notifying the health department of the medication error and the patient’s death. Everyone realized that the health department would conduct a thorough investigation of the situation, review the hospital’s policies and procedures related to medication administration, and inquire as to how nurse competencies were assessed and reviewed. The hospital attorney indicated that he and the risk management team would continue to meet with the family and suggested that social work or a clinical psychologist be involved in the meetings. The CEO met with the public relations department to prepare an official hospital statement about the situation because reporters from the community television stations were already calling and requesting information about the patient’s death.
Questions
If you were Judy, what steps would you take with your nursing staff to stabilize their emotions about the situation?
What should Judy do to stabilize the team culture so that they can all work well together again?
What steps should Judy or the hospital’s leaders take with the nurse who administered the wrong medication to the patient? Should this employee be terminated as a result of the error?
Identify both the individual errors and the system errors that contributed to the medication error.
What work needs to be done by the hospital’s leadership to manage the internal and external (public) reaction to the error and the patient’s death?
What should leadership do to help the hospital recover from this error?
