Physician and Nurse Burn – Out – Part XX. Mistakes in Children’s Medications

– “For a nurse, nothing compares to a screw-up in a kid’s medication —period.”

Louise X. is a veteran and proficient nurse that works in the Oncology ward of a large South Florida public hospital, who almost harmed an admitted child when she wrongly calculated the dilution parameters of a medication that comes in adult dosage from the manufacturer and must be adapted to lower children’s dosages. It was early dawn, and she was about to finish her nightly shift with a last round of medications for the admitted patients. The fatal error could have hurt the patient but providentially there is a protocol of double check up of these dosages in her hospital. An on-duty pharmacist picked up the mistake and quickly called her to correct it.

Note. This reproduction of a World War II US Army’s recruiting poster was taken from Wikimedia Commons.

Medication errors are frequent in all medical institutions worldwide. The National Coordinating Council for Medication Error Reporting and Prevention defines them as: “Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling; packaging, and nomenclature; compounding; dispensing; distribution; administration; education, monitoring; and use.” Traditionally Nursing Schools have taught their students to follow the Five Rights rule in their practices:

  1. Right patient.
  2. Right Drug.
  3. Right dose.
  4. Right route.
  5. Right Time.

Some reviews claim medical errors in the USA range from less than 0.2% to a whooping 10% of all prescriptions, which is difficult to determine due to under or wrong reporting; a serious study across the whole health care spectrum is needed.

Not only the nursing personnel that administers the medication is to blame but we, physicians, have a fair share of blame as we should avoid these common mistakes:

  1. We should avoid the use of confusing symbols like “U” and write the full name “Units” instead.
  2. We should avoid the abbreviations and acronyms and write the full name.
  3. We should not determine the frequency with complex signs like QD. QOD or QID, but rather spell it clearly with common vocabulary.
  4. We should not use zeros before or after a number.
  5. We should not use any abbreviations for the medications’

There should be sound prescribing policies in al major health care institutions like:

  1. Drug reference material should be available online to care personnel.
  2. Basic clinical information like age, weight, allergies, etc., should be clear.
  3. If a physician’s order is unclear, incomplete, or illegible, it should be clarified.
  4. Dispense single-dose vials and ampules, avoiding multidose vials.
  5. Whenever possible, prefer oral administration rather than parenteral routes.
  6. Avoid distracting activities like texting when you do the medication rounds.
  7. Oblige a second pharmacist to doublecheck all the dangerous medications.
  8. Be aware of look-alike or sound-like medications when you are dispensing.

Pediatric patients are especially vulnerable to any medication errors as a) they cannot clearly communicate any discomfort and b) their physiology is still immature, with the renal and hepatic clearing systems still in their early stages of operation. That is why this nurse felt that she could have harmed the child with that excessive dosage.

There is also a big factor that crosses all the segments and specialties of Health Care. There is widespread tiredness and disillusionment in our files as the persistent micromanagement of payors, the still excessive paperwork despite the widespread use of electronic medical records, the offensive demeaning of professional roles by the encroaching of management and bureaucrats, the need for constant updates, etc., has been sapping our enthusiasm, notwithstanding our strong medical vocations.

One veteran professor in our Medical School warned us, the rookies, as follows:

“Hay que dejar la medicina antes que la medicina te deje.”

(You must leave medicine before it leaves you)

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse Burn Out – Part XVIII. Medical Errors.

– “Doctor…Can’t take this s*** anymore…I am heading for the exit door—You should do the same.”

Sheila X. is a proficient Critical Care nurse that, after a medical error she committed in a medication schedule that was providentially spotted by her supervisor, decided that her work stress was too much, especially after toiling so hard in the pandemic. She could opt for an early retirement, with a nice monthly check and benefits; she did not want to risk those benefits for the sake of a few more months of work. It was time for her to quit a career she has always loved. She stopped being sentimental like so many of us still are.

In a 1999 Institute of Medicine’s publication titled To Err is Human, Building a Safer Health System, investigators found an alarming rate of medical errors in the USA, which could be at least 44.000 incidents per year, even reaching the astounding number of up to 98.000 deaths of admitted patients in hospitals and clinics. We must assume that for each incident, there might be at least one, two, three, even more nurses, technicians and physicians involved, with varying degrees of responsibility. Medical Errors could represent the third leading cause of deaths in the USA.

Note. This World War II US Navy’s recruiting poster was taken form Wikimedia Commons. At that time Women were not allowed to serve in any frontline combat positions and had to staff the auxiliary sections of the Marine Corps. That sounds so, so retrogradely condescending now. As the famous Virginia Slims poster said; “You’ve come a long way Baby.”

The IOM Committee on Quality of Healthcare in the USA stated that a Medical Error is “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” We must clarify that a priori a medical error does not imply that there has been an intentional act to commit harm to a patient or an act of medical malpractice. There are two major types of Medical Errors defined as follows:

  1. Error of Execution: the planned action does not proceed as it was intended.
  2. Error of Planning: the originally intended action was poorly designed.

Not all medical errors reach the grave status of a “sentinel incident” that must be reported to the hospital authorities and the regulating agencies for professionals. If there is a common complication like a wound infection after a major procedure, professionals must evaluate whether it was totally preventable if a mistake would not have been committed, or it was simply a complication that could not be avoided.

The Joint Committee, a national organization charged with studying Medical Errors, defined a sentinel event as “an unexpected occurrence involving the death of or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.” They proposed using the root case analysis to identify “the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event.”

There are two major types of sentinel events as follows:

I – Death of the patient or a serious permanent loss of function, not associated with the expected clinical course of the pathological condition or co-morbidity.

II – It involves one or two of the following medical conditions, which do not attain the seriousness of death or loss of a major bodily functions. They are:

  1. Suicide of an admitted patient.
  2. Unexpected death of a full-term infant.
  3. Abduction of an admitted patient.
  4. Assignment of the wrong infant to a family.
  5. Rape, battery, or assault of an admitted patient.
  6. Rape, battery, or assault of a Staff member.
  7. Administration of incompatible blood products.
  8. Post-operative retention of a Foreign Object.
  9. Severe Neonatal Hyperbilirubinemia.
  10. Prolonged Fluoroscopy with Excessive Radiation dosage.
  11. Maternal morbidity or mortality.
  12. Fire hazard.

In a series of articles, we will discuss the major types of Medical Errors and how they profoundly affect the treating personnel, not only because they might have been involved in such an instance, but also because they might be genuinely concerned that it might occur to them. Only well trained and hypervigilant professionals avoid the risk of any of them.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.