In lieu of an abstract, here is a brief excerpt of the content:

  • Who Is Responsible?

Joanne Nathan has Type 1 diabetes that she manages well. She strictly follows her diet, conscientiously gives herself insulin shots, and exercises regularly. Several days after badly bruising her knee, she experiences chest pain and shortness of breath. Her primary physician directs her to go to the ER, where she is diagnosed with pulmonary embolus (a life-threatening blood clot in her lung) and admitted to the hospital for treatment.

The usual treatment of pulmonary embolus is intravenous (IV) heparin, a drug that prevents blood from clotting. The hospital pharmacy is closed when Joanne is admitted, so Gloria, the house supervisor (a registered nurse responsible for overseeing patient care), goes to the pharmacy herself to get both the next dose of heparin as ordered and the insulin she knows Joanne will need in the morning. She takes both vials to Joanne's room and puts them in the medications drawer.

James is Joanne's nurse that night. When Joanne gets to her room, James checks her chart and sees that it's time for her next dose of heparin. As he opens the drawer to prepare the IV, he hears a code being called for a room on the opposite end of the floor. James knows hospital policy dictates that heparin must be double-checked by another nurse before being administered, but with short staffing on this—and every other—floor, plus a code in progress, he also knows that none of his colleagues really has time to do the double-check. With his mind on the code, he administers the standard dose of IV heparin and leaves the room. A little later, James pokes his head into Joanne's room and sees she is sound asleep. In thirty minutes, he returns to take her vital signs and is horrified to find her cold, damp, and unresponsive. He checks her blood sugar level. It is 20—much too low. James's stomach sinks as he opens the medications drawer. The two vials look similar, but the heparin vial is completely intact. He realizes he gave Joanne insulin instead of heparin, and that the massive dose has pushed her blood sugar so low that she is now in a coma.

During her investigation of this incident, Hannah, the hospital's risk manager, interviews Gloria. Gloria tells Hannah that James "has a history" of this: "Four years ago, when he was just out of school, James didn't double-check something—I can't remember what—with another nurse. I should have written him up when I found out, but I didn't, because he was new and young. But obviously he's a bad apple." When Hannah checks James's personnel file, she sees no mention of this previous incident.

Hannah is now about to meet with Joanna's husband, David, who wants answers: "My wife is in a coma—I want to know who's responsible."

Keeping in mind all of the factors that led to the drug mix-up, who is "responsible" for this error? What do Joanne and David need as the result of this error, right now and in the days ahead? What do the clinicians involved need as the result of this error, right now and in the days ahead? And how can this hospital demonstrate institutional responsibility for preventing errors like this one?

  • Commentary
  • Carol Bayley (bio)

An institution facing this situation should start by examining its core values to determine a response. Many hospitals' core values are founded on respect for the dignity of their patients and employees. A good way to respect this dignity is to put oneself in the place of each actor in the case, starting with the patient.

The first thing I would want, were I the patient, is complete information. What happened to me? Assuming the hospital was not out to kill me, how did it happen? And what is going to happen now? Am I likely to recover, suffer permanent damage, or remain in the hospital longer? Who will pay for my treatment? If the patient has died or is too sick to hear the answers, we owe the information to the patient's loved...


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pp. 11-12
Launched on MUSE
Open Access
Archive Status
Archived 2012
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