Medication Mix-up Contributes to Patient’s Death

Description

A patient in the Intensive Care Unit (ICU) died after receiving a medication that was intended for a different patient.

Clinical Sequence

A nurse in an ICU was caring for two patients. The first patient required vasopressors for blood pressure management, and the second patient was being treated with antibiotics for sepsis. This patient was progressing well and was scheduled for transfer to an inpatient unit once a bed became available.

The nurse called the pharmacy and requested that both patients’ medications be sent to the unit. Both medications were delivered to the ICU via the hospital tube station from the pharmacy. The nurse administered the vasopressor instead of the antibiotic for the patient with sepsis. The medication rate was incorrect and set at double the maximum dose for vasopressors. The nurse did not complete the required safety checks before starting the medication.

The oncoming nurse noted the patient’s blood pressure was over 200’s systolic. The nurses did not recognize the error and discussed possible causes of an elevated blood pressure, including abdominal pain or anxiety. The overnight nurse rechecked the patient’s blood pressure and noted it remained elevated. The patient was also experiencing a fast heart rate and increased, labored breathing.

The nurse called the resident, who noted a concerning cardiac rhythm on the monitor and then called a code blue. The charge nurse, who was assisting with the code, then recognized the wrong name on the medication label. The infusion was stopped, but the code was unsuccessful, and the patient expired later that evening.

An investigation concluded that the medication error precipitated the code and the patient’s death.

Allegation

The patient’s family alleged that a failure to follow safety protocols when administering medications contributed to the patient’s death.

Disposition

This case was settled for more than $1M.

Analysis

The nurse did not perform the required safety checks before administering the medication.

• The administration step in the medication process is considered the last line of defense before a medication reaches the patient. Verifying the “5 rights” of medication administration is essential to maintaining safety, and additional steps include (but are not limited to) right response and right documentation.

The MICU was understaffed when the medication was administered.

• Many factors can contribute to medication errors, including knowledge, personal, and contextual factors. Contextual factors are reported most frequently, including interruptions, distractions, feeling overwhelmed or rushed, and excessive workloads.^1,2
  

• The use of barcode medication administration (BCMA) technology is a vital system-level intervention that should be used whenever possible, as it can drastically reduce medication errors and improve patient safety.^3,4

Discussion Questions

1. What factors (knowledge, personal, or contextual) may have contributed to this error?

2. What are some potential system errors in this case?

3. If barcode scanning is available at your institution, what is its adherence rate?

4. Is there a process to minimize interruptions and distractions during medication administration at your institution?

5. To what degree does patient assessment (or lack of reassessment) play a role in this case?