Medication Mix-up Contributes to Patients’ Death

Description

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

Clinical Sequence

A nurse in an understaffed MICU was caring for two patients. The first patient was hemodynamically tenuous and required vasopressors (Norepinephrine) for blood pressure management. The second patient was being treated with antibiotics (Bactrim) for pneumonia. This patient was progressing well and was scheduled for transfer to a step-down unit once a bed became available.

The nurse called the pharmacy and requested that both the Norepinephrine and Bactrim be sent to the unit. Both medications were delivered to the MICU via the hospital tube station from the pharmacy. Around 6:30 p.m., the nurse administered the Norepinephrine instead of the Bactrim for the patient with pneumonia. The medication rate was also incorrect and set at the Bactrim rate, which was triple the maximum dose for vasopressors. The nurse did not complete the required safety checks before starting the medication.

Around the shift change, the oncoming nurse noted the patient’s blood pressure was 220’s systolic. The nurses did not recognize the error and discussed possible causes of an elevated blood pressure, including abdominal pain or anxiety related to the upcoming transfer. 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 cardiac rhythm on the monitor concerning pulseless electrical activity (PEA) and then called a code blue. The charge nurse, who was assisting with the code, then recognized the wrong name on the medication and realized that Norepinephrine was infusing instead of Bactrim. The infusion was stopped, but the code was unsuccessful, and the patient expired at 8:45 p.m.

An investigation concluded that the medication error precipitated the code and the patient’s death. The nurse had been employed at the hospital for five years and had no prior performance issues.

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?