ABSTRACT
Not long ago, a nurse from Wisconsin was charged with criminal “neglect of a patient causing great bodily harm” in the medication error-related death of a 16-year-old woman during labor. The nurse accidentally administered a bag of epidural analgesia instead of the intended penicillin by the intravenous route. The criminal complaint concluded that:1
The child’s attending physician and the defendant’s nurse supervisor reported that the nurse failed to obtain authorization to remove the lethal chemicals that caused the child’s death from a locked storage system. The nurse disregarded hospital protocol by failing to scan the bar code on the medication, a process of which the nurse had been fully trained and was cognizant. Had the lethal chemicals been scanned, medical professionals would have been forewarned of its lethality and the death would have been prevented. The nurse disregarded a bright, clearly written warning on the bag containing the lethal chemicals prior to injecting them directly into the child’s bloodstream. The nurse injected the lethal chemicals into the bloodstream in a rapid fashion, failing to follow the approved rate for any medications that may have been prescribed for the child, in an apparent effort to save time. The rapid introduction of these chemicals dramatically hastened the death of the child, effectively thwarting any ability to save her life. The nurse disregarded hospital protocol and failed to follow professional nursing procedures by not considering the five rights of patients prior to the administration of the lethal chemicals (right patient, right route, right dose, right time and right medication). The practice at her hospital requires the consideration of these five factors at least three times prior to the administration of any medication; the most important procedure established to prevent putting a patient’s life in jeopardy through medication errors.
