Medication error contributing factor in patient's death

Many of the patients in hospitals are already in vulnerable states. Whether it is due to disease, infection or injury, many of these patients just want to be properly treated and no longer in pain. Many of these same patients also do not know that much about medicine and rely on the nurses in the hospital to give them the proper medications, in the right amounts.

However, just like with any job, a nurse can make a mistake. But, unlike the mistake of a server or salesman, these medication errors can end up being deadly.

Recently, a hospital was fined $75,000 after a nurse made a medication error in 2011 that contributed to the death of a patient. The fine comes from the state's Department of Public Health and is not tied to a medical malpractice claim.

In this incident, the nurse accidentally gave a patient with sepsis Labetalol, which is an antibiotic that lowers the blood pressure. Normally this medication is given in small doses, not in a drip form. However, in this case, not only did the nurse give the wrong medication, but 100-milligrams was emptied into the intravenous tubing.

In this case, the patient's blood pressure ended up dropping severely and led to kidney failure. This resulted in gangrene in all of his toes and two of his fingers. Facing lifetime dialysis and pain from the gangrene, the patient said he just wanted to go to sleep. He and his family stopped all medical treatment and he passed away.

Since this medication error, the hospital has taken steps to try and prevent similar mistakes from happening in the future. These changes include moving Labetalol from an automated dispensing cabinet to a cubicle drawer where lids are only opened when specific medications are requested.

Staff also now uses bar code wands to read the bedsides, dispensing cabinets and bar codes on the medications. The hope is this will prevent patients from receiving the wrong medications.

In general, in looking at this case, the nurse accidentally dispensed the wrong medication. However, there has been other failure to administer medication cases related to the wrong dosage being given or the medication being dispensed incorrectly. All of these types of cases could end up leading to a medical malpractice lawsuit.

Source: Marin Independent Journal, "State fines Marin General Hospital for medication error that contributed to patient's death," Richard Halstead, June 6, 2013