It takes a village
Physicians will always err. It's up to other healthcare professionals to
serve as checks and balances to help prevent patient harm. When a
physician orders a medication for a procedure, whomever at the facili-
ty orders the drug should review the order before delivering the med-
ication to the point of care or to the automated dispensing system.
Again, the FDA's label change for Kenalog had been in place for 2
years before the woman's incident, so someone at the facility had a
duty to protect the patient — and all back pain patients at the center
— by alerting ordering physicians about the potential risks of Kenalog
for ESI, and perhaps even restricting it from the facility's formulary.
The patient's nurse also had a responsibility to the patient in terms
of the 5 rights of medication administration: right patient, right drug,
right dose, right route and right time. Most surgical facilities specialize
in a limited array of procedures, so nurses routinely become familiar
with various procedures and associated perioperative medications.
Nurses often witness or play a role in informed consent, so they had
an additional opportunity to prevent the use of Kenalog by ensuring
that the patient understood what was going to happen.
If the nursing team wasn't familiar with Kenalog, then it was their
responsibility to educate themselves so they could advocate for the
patient and ensure the 5 rights. In the Colorado case, that would have
afforded another opportunity to confer with the pharmacist and order-
ing physician to avoid a catastrophic error.
The surgery center itself also had an administrative duty because it
employed the nursing and pharmacy teams, and should have been
aware that Kenalog was routinely purchased and administered for
epidural injections despite explicit FDA and manufacturer warnings.
Medical Malpractice
MM
3 0 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • M A Y 2 0 1 9
