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M E D
A
S A F E T Y
re you reading these words thinking a medication error
won't happen on your watch because you're good at what
you do and can't possibly make mistakes? I know someone
like you. Several years ago, a 16-year veteran nurse with exemplary
job performance ratings accidentally injected a patient with insulin
instead of heparin because the syringes happened to be sitting next
to each other. Later, she broke down in my office. "I didn't think I
was capable of making that error," she said between sobs. "I discounted the possibility every time I read about similar incidents."
Take it from me, errors and oversights can in fact happen to you.
Unlabeled medication vials in the OR had deadly consequences at Virginia
Mason Medical Center in Seattle, Wash. The surgical staff there mistakenly
injected Mary McClinton with the prepping agent chlorhexidine instead of a
marker dye during a brain aneurysm procedure in 2004. Both substances
were colorless and clear, and the receptacles containing the liquids were
unlabeled. The highly toxic chlorhexidine caused kidney failure, a sudden
drop in blood pressure and a stroke. Ms. McClinton died less than a month
later. The case made national news, partly because of the hospital's willingness to apologize publically for the devastating mistake and help educate
other facilities to avoid similar fates.
1. The unlabeled vials
The surgical team in this case was lulled into a false sense of secuM A R C H 2013 | O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E
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