Medical Mix-Up: Five Ways A Patient Could Have Been Saved from Death

The root cause of these problems is not in the events that led to the error.

According to a Lexington News Station Lex18, a series of events led to the death of a man who died needlessly due to a mix-up of medical solutions. Here I present the events in a timeline suitable for a case study on medical errors according to documents from a Kentucky Board of Nursing investigation:

Here's a timeline reconstructed from the information provided:

1. Last summer: An 81-year-old man is transferred to CHI Saint Joseph Health Main in Lexington due to a gastrointestinal bleed requiring a higher level of care.

2. June 30, 2022: The patient is admitted under the care of a nurse. The dialysis team leaves a jug of dialysis liquid (Naturalyte) on the ICU floor. This jug is left unattended and is mistaken for a colonoscopy prep called GoLytely.

3. June 30, 2022, around 5:35 p.m.: The nurse attempts to scan the jug of dialysis liquid (mistaken for GoLytely), but the barcode does not scan. She calls the hospital pharmacy to inform them about the issue.

4. June 30, 2022, approximately 5:40 p.m.: The pharmacy sends a label for the jug to the ICU floor through a tube system.

5. June 30, 2022. Before the end of her shift, the nurse administers about 8 oz. of Naturalyte (mistaken for GoLytely) to the patient. The patient is "unable to tolerate" the liquid.

6. June 30, 2022. After the first nurse's shift: A doctor orders that the patient should take the full amount of colonoscopy prep. A different nurse then administers the rest of the Naturalyte through a feeding bag.

7. June 30, 2022, (around midnight): The medication mix-up is identified.

8. July 1, 2022, approximately 7:35 a.m.: The patient passes away.

In the subsequent months, investigations into the incident are carried out by the Kentucky Board of Nursing and local media. The nurse involved undergoes training on how to avoid medication errors.

Five Ways This Death Could Have Been Prevented

Based on the information provided, the following are potential strategies that could have prevented this fatal medication error:

1. Effective Communication between Nursing and Pharmacy Staff: When the nurse called the pharmacy to inform them that the jug of medication wouldn't scan, the pharmacy could have asked for more details about the medication or even suggested “When In Doubt, Throw it Out”. The decision to send a new label for the jug without verifying its content could be viewed as a critical communication failure.

2. Distinctive Medication Labeling and Product Naming. The shape, color and text of medical products should be made distinctive and should be named in a manner that implies use (e.g., “ColonoLyte” vs. “DialysisLyte”).

3. Medication Storage and Management: The dialysis liquid (Naturalyte), which is not meant for ingestion, was left on the ICU floor for up to three days. There should be a clear policy regarding the appropriate storage, disposal, and segregation of medications and other substances. Medications should be stored in designated areas, and any unused or unneeded medication should be promptly removed and disposed of following the appropriate protocols.

4. Double-checking the Medication: Despite the barcode not scanning, the nurse failed to double-check the medication's label visually before administering it. Incorporating a practice of visually checking and re-confirming the medication, its dose, and its appropriateness for the patient before administration could have helped in preventing this error.

5. Nurse-Patient Ratio: The nurse in question was managing more patients than usual due to understaffing on the shift. Overloading nurses with too many patients can lead to errors due to increased stress and workload. Ensuring appropriate nurse-to-patient ratios can help ensure that each patient receives enough attention and care and reduce the chance of errors.

The research needed to identify solutions is minimal; policymakers focused on saving face or hospital administrators focused on minimizing public awareness of medical errors such as this event are the root cause of the failure of adoption of common-sense solutions such as these.