Somehow, I think these types of errors have probably increased to some degree following the exodus of so many skilled medical professionals who refused the experimental jab.
Maybe but it doesn't take a highly skilled nurse to administer an oral medication. Any nurse can be expected to give the right med in the right dose by the right route at the right time to the right patient. Those are called the 5 rights. Labels should be triple checked for accuracy. Having computers to scan bar codes doesn't relieve you of responsibility. I hope this family does sue bc I'm just a retired RN and I can pick this case apart. Theres no excuse for the pharmacy to send a new label not knowing what the nurse was trying to scan. I even question why that particular prep was ordered for an 81 year old man in icu. That's a lot of fluid and there are other preps available.
I also think the patient “not tolerating” the administration of the stuff might have made that nurse wonder back to the fact it would not scan ... WHAT IF IT ISNT WHAT SHE ASSUMED IT WAS? But this nurse is too harried and rushing along to put the pieces together. I’m the end, intelligent and well-trained nurses who are encouraged to question protocol and treatment based on impact to patients, are the very best way to provide highest quality care. The poor patient and his poor family! Needless tragedy unless ... unless you can implement changes based on it???
My dad wife & best friend were all killed by iatrogenic "medicine" as were 250,000 to 800,000 others each & every year, according to the Johns Hopkins [low-ball] iatrogenic study or the well documented, book, Death by Medicine by Dr. Null! i.e. not counting pharma's gain of function, SARS 2 Co v 19 biowarfare kills!
"The decision to send a new label for the jug without verifying its content could be viewed as a critical communication failure."
The decision to send a new label for the jug (bonus: a jug that was lying around on the floor) could be construed as malpractice, malfeasance, homicide, or people who are too stupid to be a pharmacist and a nurse.
About 15 years ago, I worked in a large DC area hospital. A young pre-op patient switched beds when her room mate was discharged, to be next to the window. When a central lab tech checked her blood type, they read the discharged patient’s chart. During her operation, she died - incompatible blood. The hospital tried to cover the accident up for about a year, while refusing to settle with the victim’s family. . . . Doctors are good, nurses are great, hospitals are run by MBAs, lawyers & accountants.
There's a reason nurses are supposed to be trained medical professionals who take 4 years of education and then have to pass an exam to become licensed to practice. They are supposed to have critical thinking skills, able to analyze a situation and problem solve. I was a nurse for 35 years and spent the last 12 years of my career in Informatics, deploying, training and evaluating the use of technology at the bedside. Scanning the patient barcode and then scanning a medication to match it to an order was supposed to improve patient safety, but it was not a substitute for critical thinking skills. When the scan did not match, it was incumbent on the nurse to determine the problem (wrong patient, wrong order, wrong medication, wrong dose, wrong time) and work from there. Clearly that didn't happen in this case. Instead she decided the medication was labeled wrong and asked Pharmacy to fix it. This would be like going to the grocery store and buying $60 worth of filet mignon and at checkout telling the cashier, this barcode is wrong, it's really $5 of hamburger, can you change the barcode so it's correct? Except, no one's going to die from that. In this case someone did. So you get my point. It was stupidity on the nurse's part and pharmacist's part as well. Hospitals have become death camps since those with the mental capapcity to make intellectual decisions have been runoff by the mandated vaccines. Stay as far away from them as you possibly can.
This isn’t a new issue only recently magnified. 10.5 years ago when I was 30 weeks pregnant, I had a medical issue that sent me to the ER. All I wanted was the nurse to check my child’s heartbeat to make sure he was ok. First she had to take my blood pressure. When the machine failed, she was not capable of doing it the old fashioned way and had to bring in an older nurse. They made at least 4 other errors while I was there that would have put most young pregnant mother’s in danger. Be brave and well informed when going to a hospital.
It is horrifying to see the loss of critical thinking in clinical practice. The 5 R’s have been replaced by the bars. Barcode med administration was meant to enhance safety, not replace basic nursing skills.
Unfortunately, I don't think loss of common sense and critical thinking is isolated to nursing. I've encountered it in about every profession lately. I recently had my debit card locked for suspected fraudulent activity. I had gotten an email from my bank that looked like a phishing scam so I didn't open it. I get probably 3 or 4 a day from Amazon, Netflix, you name it, about how my payment couldn't be processed and I need to click here and put my info in or my account will be closed. I don't even open them anymore because I know they are scams. Then I got 2 calls from an 800 number that left an automated vm that I needed to call an 800 number right away about activity on my account. I pulled my account up on line and there weren't any charges I hadn't made or out of the ordinary, so I called my bank. I told them about the calls and email, they forwarded me to the credit card department who looked at my account, said everything was fine and there were no fraud alerts on my account and that I had done the right thing by not responding to those emails or calls. The next day, on Saturday I went to make a purchase of $8 at a store and my card was declined. Tried to buy some groceries for $30 after that and card was declined again. When I got home, I opened the email I had gotten and it appeared to have actually come from my bank and listed 4 charges that had prompted the fraud alert. One to Kroger for $130 for groceries, one for $100 for my hairdresser, one to ATT for $101 for my cellphone bill and an automatic withdrawal from Amazon for $146 for my annual Prime membership. All total less than $500. I guess we're big spenders at my house. So I called the number for the fraud department in the email to find out why my card had been locked. I will just say it was the most confrontational call I've ever had with a financial company. After asking my name and last 4 of my social, the lady wanted the full card number and 3 numbers on the back of the card. I told her I wasn't comfortable providing that since she should already know that. She said she had to have that to verify to determine my identity. Then she says, I'm going to name an amount, and you need to tell me what that was for. She named the amount for my cellphone bill and I told her. Then she says, "That $146 to Amazon, did you make that purchase willingly or were you coerced into making it?" I said, "excuse me?" "Maam, did someone coerce you into making that purchase?" I said, "It's an automatic payment that comes out once a year. I don't understand what you are getting at. In fact I don't understand any of this. Do credit card thieves typically buy groceries and get their hair done? Because none of those charges should have prompted a fraud alert in my opinion. I tried to buy an item for $8 yesterday and my card was declined. Do you know how embarrassing that is when you have more than enough money to cover what you are buying ? " Then she begins to scold me for ignoring their emails and phone calls and says, "Maybe next time we call you'll be more proactive and we won't have to lock your card." I told her I did call my bank and they assured me my card was fine, and further more, by her saying "next time" it sounded a lot like they were monitoring my purchases and card activity which could be interpreted as spying on a private citizen which I believe is unconstitutional and against the law. You could tell she wasn't prepared for this response because she said, "when we hang up, your card will be active." On Monday, I went to my bank and met with the manager to tell him about the problems I had and the response I had gotten from the fraud department. You would think he would have at least offered an apology since when I called his bank on Friday they had told me everything was fine or tried to see where the breakdown was. Nope. He tried to make excuses for her comments and behavior. I might think I was crazy, but this is just one in a long string of stupidity I've dealt with in the financial industry. Chase Manhattan bank once started foreclosure on our mortgage years ago because someone who lived in the same city had a name similar to mine had filed bankruptcy. Not the same name, but similar. I mean why do they need all those social security numbers and things when you close on a loan if they are going to just go by similar names when they do things? If I hadn't called because we hadn't gotten our bill in the mail 2 months in a row I wouldn't have even known it. And I was making my payments on time every month. Even that didn't clue them in it was the wrong person. But the best one was when $11,000 showed up in my account and I had no idea where it came from. I went to the bank to try and find out how it got there and they didn't know either. This was in the early 80's before the internet and computers. They were going to check on it, so after a couple of weeks I went back to the bank and asked again. They again said they had no idea where it came from, so I could just keep it. I argued with them, that someone was missing $11.000 and it wasn't right that they didn't find out who it belonged to. No one at the bank seemed too concerned about it. We ended up putting it into college funds for our kids, but it's always made me uncomfortable because I know someone deposited that money and who knows how long it was before they went back to get it.
Somehow, I think these types of errors have probably increased to some degree following the exodus of so many skilled medical professionals who refused the experimental jab.
Maybe but it doesn't take a highly skilled nurse to administer an oral medication. Any nurse can be expected to give the right med in the right dose by the right route at the right time to the right patient. Those are called the 5 rights. Labels should be triple checked for accuracy. Having computers to scan bar codes doesn't relieve you of responsibility. I hope this family does sue bc I'm just a retired RN and I can pick this case apart. Theres no excuse for the pharmacy to send a new label not knowing what the nurse was trying to scan. I even question why that particular prep was ordered for an 81 year old man in icu. That's a lot of fluid and there are other preps available.
I agree completely but also believe an overworked, short staffed, team is much more likely to make mistakes. I, too, hope a lawsuit is filed!
I also think the patient “not tolerating” the administration of the stuff might have made that nurse wonder back to the fact it would not scan ... WHAT IF IT ISNT WHAT SHE ASSUMED IT WAS? But this nurse is too harried and rushing along to put the pieces together. I’m the end, intelligent and well-trained nurses who are encouraged to question protocol and treatment based on impact to patients, are the very best way to provide highest quality care. The poor patient and his poor family! Needless tragedy unless ... unless you can implement changes based on it???
The brain evaluates the images it is processing against what feels good, not the facts, most of the time! I.E. over riding the bar code mismatch!
My dad wife & best friend were all killed by iatrogenic "medicine" as were 250,000 to 800,000 others each & every year, according to the Johns Hopkins [low-ball] iatrogenic study or the well documented, book, Death by Medicine by Dr. Null! i.e. not counting pharma's gain of function, SARS 2 Co v 19 biowarfare kills!
I came here to say this. Here’s a link, if anyone is interested in the data: https://journals.lww.com/journalpatientsafety/fulltext/2013/09000/a_new,_evidence_based_estimate_of_patient_harms.2.aspx
Dialysate down a feeding tube. Now I've heard everything. Do not miss hospital practice.
"The decision to send a new label for the jug without verifying its content could be viewed as a critical communication failure."
The decision to send a new label for the jug (bonus: a jug that was lying around on the floor) could be construed as malpractice, malfeasance, homicide, or people who are too stupid to be a pharmacist and a nurse.
Yep. Read the effing label. I'm sure that it didn't say drink 8 oz.....
Yep!
Hope the family sued the hospital and received their due money! This is horrible!
About 15 years ago, I worked in a large DC area hospital. A young pre-op patient switched beds when her room mate was discharged, to be next to the window. When a central lab tech checked her blood type, they read the discharged patient’s chart. During her operation, she died - incompatible blood. The hospital tried to cover the accident up for about a year, while refusing to settle with the victim’s family. . . . Doctors are good, nurses are great, hospitals are run by MBAs, lawyers & accountants.
Precisely. Never fix what you can hide.
What is the average iatrogenic/ hospital caused deaths per year?
800k?
According to the article I posted in reply to another poster, the number is around 400,000 per year, pre-Covid.
There's a reason nurses are supposed to be trained medical professionals who take 4 years of education and then have to pass an exam to become licensed to practice. They are supposed to have critical thinking skills, able to analyze a situation and problem solve. I was a nurse for 35 years and spent the last 12 years of my career in Informatics, deploying, training and evaluating the use of technology at the bedside. Scanning the patient barcode and then scanning a medication to match it to an order was supposed to improve patient safety, but it was not a substitute for critical thinking skills. When the scan did not match, it was incumbent on the nurse to determine the problem (wrong patient, wrong order, wrong medication, wrong dose, wrong time) and work from there. Clearly that didn't happen in this case. Instead she decided the medication was labeled wrong and asked Pharmacy to fix it. This would be like going to the grocery store and buying $60 worth of filet mignon and at checkout telling the cashier, this barcode is wrong, it's really $5 of hamburger, can you change the barcode so it's correct? Except, no one's going to die from that. In this case someone did. So you get my point. It was stupidity on the nurse's part and pharmacist's part as well. Hospitals have become death camps since those with the mental capapcity to make intellectual decisions have been runoff by the mandated vaccines. Stay as far away from them as you possibly can.
This isn’t a new issue only recently magnified. 10.5 years ago when I was 30 weeks pregnant, I had a medical issue that sent me to the ER. All I wanted was the nurse to check my child’s heartbeat to make sure he was ok. First she had to take my blood pressure. When the machine failed, she was not capable of doing it the old fashioned way and had to bring in an older nurse. They made at least 4 other errors while I was there that would have put most young pregnant mother’s in danger. Be brave and well informed when going to a hospital.
It is horrifying to see the loss of critical thinking in clinical practice. The 5 R’s have been replaced by the bars. Barcode med administration was meant to enhance safety, not replace basic nursing skills.
Unfortunately, I don't think loss of common sense and critical thinking is isolated to nursing. I've encountered it in about every profession lately. I recently had my debit card locked for suspected fraudulent activity. I had gotten an email from my bank that looked like a phishing scam so I didn't open it. I get probably 3 or 4 a day from Amazon, Netflix, you name it, about how my payment couldn't be processed and I need to click here and put my info in or my account will be closed. I don't even open them anymore because I know they are scams. Then I got 2 calls from an 800 number that left an automated vm that I needed to call an 800 number right away about activity on my account. I pulled my account up on line and there weren't any charges I hadn't made or out of the ordinary, so I called my bank. I told them about the calls and email, they forwarded me to the credit card department who looked at my account, said everything was fine and there were no fraud alerts on my account and that I had done the right thing by not responding to those emails or calls. The next day, on Saturday I went to make a purchase of $8 at a store and my card was declined. Tried to buy some groceries for $30 after that and card was declined again. When I got home, I opened the email I had gotten and it appeared to have actually come from my bank and listed 4 charges that had prompted the fraud alert. One to Kroger for $130 for groceries, one for $100 for my hairdresser, one to ATT for $101 for my cellphone bill and an automatic withdrawal from Amazon for $146 for my annual Prime membership. All total less than $500. I guess we're big spenders at my house. So I called the number for the fraud department in the email to find out why my card had been locked. I will just say it was the most confrontational call I've ever had with a financial company. After asking my name and last 4 of my social, the lady wanted the full card number and 3 numbers on the back of the card. I told her I wasn't comfortable providing that since she should already know that. She said she had to have that to verify to determine my identity. Then she says, I'm going to name an amount, and you need to tell me what that was for. She named the amount for my cellphone bill and I told her. Then she says, "That $146 to Amazon, did you make that purchase willingly or were you coerced into making it?" I said, "excuse me?" "Maam, did someone coerce you into making that purchase?" I said, "It's an automatic payment that comes out once a year. I don't understand what you are getting at. In fact I don't understand any of this. Do credit card thieves typically buy groceries and get their hair done? Because none of those charges should have prompted a fraud alert in my opinion. I tried to buy an item for $8 yesterday and my card was declined. Do you know how embarrassing that is when you have more than enough money to cover what you are buying ? " Then she begins to scold me for ignoring their emails and phone calls and says, "Maybe next time we call you'll be more proactive and we won't have to lock your card." I told her I did call my bank and they assured me my card was fine, and further more, by her saying "next time" it sounded a lot like they were monitoring my purchases and card activity which could be interpreted as spying on a private citizen which I believe is unconstitutional and against the law. You could tell she wasn't prepared for this response because she said, "when we hang up, your card will be active." On Monday, I went to my bank and met with the manager to tell him about the problems I had and the response I had gotten from the fraud department. You would think he would have at least offered an apology since when I called his bank on Friday they had told me everything was fine or tried to see where the breakdown was. Nope. He tried to make excuses for her comments and behavior. I might think I was crazy, but this is just one in a long string of stupidity I've dealt with in the financial industry. Chase Manhattan bank once started foreclosure on our mortgage years ago because someone who lived in the same city had a name similar to mine had filed bankruptcy. Not the same name, but similar. I mean why do they need all those social security numbers and things when you close on a loan if they are going to just go by similar names when they do things? If I hadn't called because we hadn't gotten our bill in the mail 2 months in a row I wouldn't have even known it. And I was making my payments on time every month. Even that didn't clue them in it was the wrong person. But the best one was when $11,000 showed up in my account and I had no idea where it came from. I went to the bank to try and find out how it got there and they didn't know either. This was in the early 80's before the internet and computers. They were going to check on it, so after a couple of weeks I went back to the bank and asked again. They again said they had no idea where it came from, so I could just keep it. I argued with them, that someone was missing $11.000 and it wasn't right that they didn't find out who it belonged to. No one at the bank seemed too concerned about it. We ended up putting it into college funds for our kids, but it's always made me uncomfortable because I know someone deposited that money and who knows how long it was before they went back to get it.