Tragic Medication Errors Result in

Accidental Abortions and Premature Birth

August 21, 2009
By AVNI PATELd T
a Sampson suffered brain damage and remains hospitalized due to health complicatio
In a span of only a few hours, nurses at a Florida hospital operated
by the giant Tenet Healthcare Corporation mistakenly gave two pregnant
women a drug commonly used to force dead fetuses out of the womb. One
woman lost two unborn twins and the second gave premature birth to a
daughter who suffered severe brain damage.
One of the women is now suing Tenet in cases that safety advocates say
underscore the continuing problem of prescription errors that should and
could old be easily caught.
"These two women were supposed to be safe, on bed rest, and the worst
possible thing happened to them," said David Kelly, an attorney
representing Tesome Sampson, and her 11-month old daughter Traniya,
who suffered brain damage and remains hospitalized due to health
complications.
Sampson was five-and-a-half months pregnant when her doctor ordered
her to strict bed rest at St. Mary's Medical Center in West Palm Beach last
August.
But instead of giving her the progesterone suppositories the doctor had
ordered to prevent premature labor, the hospital staff mistakenly gave her a
dosage of Prostin, a powerful drug used to induce labor and expel fetuses
out of the womb after miscarriages, according to a complaint filed in a
Florida court.
After four hours of extreme abdominal pain and cramping, Sampson gave
birth to Traniya, expelling her in a commode after nurses said she just
"needed to have a bowel movement."
Submitted by: Wendell Escalante

Reaction:
Similar to other studies, no single or combination of nurse demographic
characteristics were strongly associated with nurse perceptions of medication
errors or the reporting of medication errors. Thus, all nurses in an organization
may need help in identifying what is a medication error, when to report it, and to
whom. What this means for nurses working on quality and patient safety
programs is that, most likely, there are no specific groups of nurses to target for
interventions or education. For example, inexperienced nurses are not reporting
more or less errors than do experienced nurses. This once again emphasizes
systemic problems at issue in regard to medication errors
in personnel," said Michael Cohen of the Institute for Safe Medication Practices, a
Pennsylvania-based non-profit group dedicated to medication error prevention.
Medication safety advocates say such serious yet avoidable errors continue to
occur, despite a decade-long effort to improve hospital systems.
"There really are so many things that can go wrong -- so many procedures,
processes, changesStudies estimate that 400,000 preventable drug-related
injuries occur every year, according to a 2006 by the National Academies' Institute
of Medicine.
Often, the mistake originates with a doctor's scribbled handwriting, which
appears to have been a contributing factor in the Sampson case. Part of the
problem, says Cohen, is that only 10 to 12% of hospitals have computerized
systems that can be used by doctors.
Look-alike and sound-alike drugs are also a source of concern. For example,
Cohen's group has compiled a list of more than a thousand commonly confused
drugs.
Cohen says that when tragic errors like the ones at St. Mary's occur, hospitals
have a responsibility to work with federally certified patient safety organizations
to conduct a top-to-bottom review of hospital procedures and systems to ensure
such errors never happen again.

Tootsies Story: Medical Error Takes a Life
Jennifer Bellot, PhD, RN, MHSA, is an assistant professor at Thomas
Jefferson University and a Robert Wood Johnson Foundation Nurse Faculty
Scholar. This is Part One of a two-part blog about the death of her beloved
grandmother.
Just over a year ago, our family lost our beloved matriarch and my
grandmother, Tootsie, to complications from a medical error. Its hard to
believe that its been over a year now and each day, we feel her lossor
presencein different ways. I write about this remarkable woman in this
months issue of Professional Case Management.
Tootsie was an amazing example of strength, generosity, and perhaps most
characteristically, of someone who spent her life caring for others. She bore eight
children in nine years, raised them almost single-handedly after her husband died
prematurely, and managed a 160-acre farmall without a high school degree.
Tootsie and I had an especially close relationship, blossoming one summer when I
lived with her as a preschooler while my mother pursued her graduate degree.
As I grew older, I would become involved in Tootsies medical management.
She would regularly send me copies of her lab reports and medical records.
Medical talk became our currency of love. We chatted about her latest cardiology
consultation like others might chat about celebrity gossip. Following and
safeguarding her health was how we shared our love best.
No doubt, age encroached upon Tootsie with a typical chronic-disease
narrative. She lived independently and managed her underlying congestive heart
failure and one kidney well through diet and activity. Bilateral cataracts sidelined
her ability to drive and her portable oxygen tank made it difficult to board the
bus, but there was always a will and always a way if it meant meeting friends for
lunchevery single day.
One day, a routine visit from my aunt found Tootsie short of breath with a
racing heart. A visit to the local emergency room found that, due to a medical
error, Tootsie had been overdosing on Synthroid for the previous two weeks. Her
fragile heart had run amuck. No one knows quite how this
happened. Somewhere between her doctors medication order and what was
placed in the prescription bottle, Tootsies Synthroid dose was drastically
incorrect. Six cardioversions, a stay in the intensive care unit, and multiple
consultations and tests later, Tootsie was exhausted. Her heart had been
overtaxed for two weeks, sending her into irreversible congestive heart failure
and resultant fluid imbalance, kidney failure, pneumonia and anemia.
In the final five months of her life, Tootsie went home for a total of 2.5
days. In the meantime, she had at least six hospital admissions at two facilities
that involved three intensive care stays, six visits to the emergency department, a
cardiac catheterization, five units of blood, an upper endoscopy and a startling
number of chest x-rays, EKGs and blood tests. She quickly became deconditioned
and spent every day that she was not in the hospital as a resident of the adjoining
nursing home, determined through therapy and exercise to regain her
independence.
As she was struggling in her final days, I spoke with Tootsie about what we
could do to make her experience beneficial for others. She had no interest in
suing the provider or pharmacy behind her initial Synthroid overdose. But, we
agreed that a good option would be for me to tell her story, so others might avoid
similar missteps.
Partially to deal with my own grief, I combed Tootsies medical records, for
what I did not know. I was looking for something, anything, to make sense of
those final five months. What I learned was that no amount of industry
knowledge on my part, no amount of elder advocacy and no keen interest in
Medicare could have saved Tootsie from a textbook case of error, difficult
transitions in care, unnecessary intervention, missed opportunities, and
conflicting opinions and prognoses. No matter how good Tootsies medical care
was, non-clinical factors such as hand-off communication, caregiver coordination
and outpatient care management and support were overlooked. The critical piece
that was missing or diminished in each of these instances was the role of the
nurse. Her case was, simply and sadly,quite typical.
Reaction:
Medication administration to patients is a part of clinical nursing practice
with high risk of errors occurrence. The causing factors of medication errors are
either individual or systemic. In order to prevent errors before, the establishment
of protective measures is pivotal. The protective measures against medication
errors are related with the preparation and administration of medications, the
dosing calculations skills of nurses, the nursing education, the oral medication
orders, the interdisciplinary collaboration, the manager nurses and changes in
health systems issues relevant with medication management.
medical/nursing interventions or patient hospitalization have drawn health
researchers attention over the last decade. Errors appearing in the hospital
settings concern a lot of incidents like patients falls, use of wrong equipment,
sores, hospitals infections, improper management of clinical situations and
medication errors. Medication error defined as any preventable event that may
cause or lead to inappropriate medication use or patient harm while the
medication is in the control of health professional, patient or consumer.
Studies that examined the types of medication errors divided them in
categories, according to the description of the event: omission error, wrong drug
error, wrong patient error, wrong route error, wrong time error, wrong technique
error, wrong dosage-form error and extra dose error.4 Thus, to avoid any type of
medication error made by nurse, the implementation of preventive measures is
undoubtedly beneficial. Nurses taking into account all precautions for medication
errors, reduce firstly the incidence of medication errors, maintain the culture of
safe hospital environment and ensure safe medications management by them.