“Personal accountability” is the new hot topic in hospital conversations. We are all accountable for our decisions and our actions. Every time we speed, run a red light, fail to use our seatbelts, or forget to wash our hands, we’re putting ourselves and/or others at risk. The same is true for failing to use safety […]
“Personal accountability” is the new hot topic in hospital conversations. We are all accountable for our decisions and our actions. Every time we speed, run a red light, fail to use our seatbelts, or forget to wash our hands, we’re putting ourselves and/or others at risk. The same is true for failing to use safety technology that is available to help prevent high-risk medication errors. In a recent webcast hosted by the CareFusion Center for Safety and Clinical Excellence, an expert faculty discussed the risks clinicians take when they choose not to use available safety technologies. It is clear that we are entering a new era of personal accountability and, therefore, personal risk.
Since our webcast, we have learned of two additional errors that had tragic consequences. In a Chicago hospital, a neonatal nutritional formula was compounded in error as a result of a technician’s mistake that led to a 10-fold overdose of sodium chloride. The nutritional formula was prepared using a computerized compounding machine that is highly accurate in its preparation – it measures out each ingredient in exactly the amount as programmed. Unfortunately, the pharmacy technician programmed 10-times more sodium chloride than what the physician had ordered. For reasons that have not been disclosed, the dose checking software feature that could have alerted the technician and pharmacist to this error was not operational. The overdose of sodium chloride resulted in the baby’s death. In this case, the technician was a victim of someone else’s choice to neglect the technology’s safety features.
We also recently learned of a nurse who administered a 10-fold overdose of calcium that led to the death of a neonate, and afterward, took her own life. While there are no facts that point to a choice to not use available safety and error alert technology, this story reveals the deep feelings of guilt and personal grief that engulfed this competent and experienced caregiver.
These stories reminded me of the “second victim” of medication errors – a concept that’s been discussed by several national experts. The focus on the second victim began in 2006 when a Wisconsin nurse failed to use a bar code system that might have prevented a patient’s death when she administered an epidural infusion intravenously, instead of an IV antibiotic. The nurse was terminated, charged with two felony counts and ultimately was prohibited from direct patient care for a 5-year period. She has since revealed that she also considered taking her own life.
Clearly, the adoption and proper use of technology that can improve safety requires changes in long-standing practices and introduces new legal risks. Change is never easy, but addressing these issues is necessary. Our patients demand and deserve the safest care we can provide.