What happened
IV Error
Mrs. Kelly, 55, was rushed to the ER by her daughter after feeling sick for several days. In the ER, the patient was stabilized with the plan of admission to the hospital once her primary physician called back the ER physician. At about the same, the emergency room was informed that two victims of a train accident would be arriving in 15 minutes; the ER physician took the decision to admit Mrs. Kelly tot the medical floor. Shortly after the admission, the ER phoned me to inform me that Mrs. Kelly’s physician had returned his call and instructed that the patient be instead admitted to our intensive care unit (ICU) to receive cardiac monitoring. Through the intercom, I immediately informed Nurse Mary who was already in the process of admitting Mrs. Kelly to the medical floor that the patient was to be transferred to the ICU instantly. I also asked the nurse Mary to ensure that the patient was stable and stay with her as another nurse would be there in a short time to help in the transfer to the ICU.
As I later learned, Nurse Mary checked the physician’s orders and noted that the IV was set as normal saline (NS) at 150cc/hr. Nurse Mary further checked the IV fluid to note that it was NS while the rate was ordered at 5cc/hr on the IV pump. She then took the decision to increase the rat to 150cc/hr. The co-worker I had asked to assist with the transferring of Mrs. Kelly to the ICU arrived shortly thereafter and Nurse Mary stopped perusing the physician orders. The two nurses assisted each other in transferring Mrs. Kelly to the ICU. Nurse Mary informed the ICU nurse that she checked the physician’s orders halfway, so the ICU nurse needed to double check the orders in full. Nurse Mary and her co-worker then returned to their respective units to continue with caring for other patients.
A little while later, phoned the medical floor to inquire if anyone had adjusted the IV pump. Nurse Mary responded truthfully by stating that she had earlier increased the pump’s rate to 150cc/hr as per the physician orders. I learned that the ICU nurse had informed nurse Mary that a 100cc bag of insulin was drooping behind the bag of NS and running through the pump. Nurse Mary admitted that she had noticed the small bag of IV bag but assumed that the tubing in the IV pump was originating from the bag of normal saline. This is a near-fatal patient safety incident at our hospital on that day considering that the patient had missed by a whisker to receive an overdose of insulin before the ICU nurse noticed the error.
My feelings and thoughts
The near fatal incident at the hospital got me very apprehensive. My anxiety stemmed from the understanding that adverse effects in patient safety are largely as a result of medication administration errors. These kind of errors account for 26 percent to 32 percent of all medication errors at multidisciplinary hospitals like ours – most of which are administered by nurses.
The incident awoke to the fact the crucial role of nurses in the health care giving process in the hospital. The decisions by nurse Mary awoke to the fact that the life of a patient is often largely in the hands of a nurse attending to him or her. To a larger extent, patient’s safety is in the hands of nurses because they are the ones who keep an eye on the patient’s electrolytes and fluids in addition to deciding whether the patient needs a central line for their IV or a feeding tube. Of even greater significance, I was reminded that nurses question physicians’ order more times than we might think.
As one would guess, as secretary of the hospital, I could not help thinking of the potential implications had the patient safety scare at our hospital materialized. There is no doubt that an insulin overdose on Mrs. Kelly would have ended up in her loss of life. Besides causing harm to the patient, a fatal compromise to patient safety would have cost us significant amounts of money as well as waste of our resourceful time. This would have such adverse ripple effects as litigation, a dent to the reputation of our hospital, and rolling of heads at the institution including Mary and others found culpable following an investigation. I was only appreciative of the fact that Mrs. Kelly’s case was a near fatal incident considering that majority of medication administration errors are not intercepted in time resulting in adverse outcomes such as death.
However, the incident made me realize the need of change at the hospital as relates to patient safety.
