Lack of coordinated information
Medication errors are often caused by information not being passed on at staff handover
An elderly man came into a hospital to have an investigation of a bowel problem. He was otherwise well and lived independently. Medication errors were the last thing on his mind. All he know was that he suffered from chronic constipation and stomach bloating and that his GP was concerned it might be cancer.
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The hospital doctor ordered a CT scan with contrast, to get a clear picture of the man’s abdomen. Because the dye used in CT contrast was know to be dangerous for people with existing kidney disease, the doctor ordered a blood tests, to check the man’s kidney function. The test showed that the man’s kidney function was poor and he had chronic renal failure. Because this disease does not affect people until it is end stage, the man had no symptoms.
The senior doctor told a resident doctors to write up a drug, to be given before the man had his CT with contrast scan. This drug was know to provide protection from the damaging dyes used in contrast scans. The resident doctor wrote the drug up. He then went looking for the nurse allocated to the patient, to make sure she gave the drug.
The resident couldn’t find the right nurse. She was off the ward picking up a patient from theatre. However he found one of the senior nurses on the ward. The resident doctor repeated several times that it was very important this man have the drug, before his scan. The nurse assured him this would be done. In the meantime the patients scan was cancelled. There was a change of nursing shift. The CT scan was cancelled several more times. The ward was very busy that evening, with a lot of post operative patients coming back to the ward.
Finally, late at night radiology called to say they were ready to take the man for his scan. Another nurse was sent to escort the patient. She was not looking after this patient and had no idea about the drug being meant to be given before the scan.
A few days later the man became very unwell. Blood tests showed his kidneys had failed completely. The doctors checked the drug chart and saw that the order for the drug to protect the mans kidney had not been given. The doctors were extremely angry and confronted the nurse looking after the man that shift. She had no idea about the drug, or why her patient was unwell. She had never seen the patient before. The senior nursing staff were called in to explain.
They realised the mistake and rang the night nurse to find out why she hadn’t given the drug before the scan. In the mean time the patient was given a number of drinks to try and bring his blood potassium levels down. The drinks failed, and his blood potassium levels kept rising.
Within a week the patient needed dialysis. The dialysis team was urgently called to assess him for hemodialysis. Due to his advanced age, they declined to accept him. Services were limited due to the cost of the program. The man deteriorated rapidly, and was referred to palliative care. Four weeks after the scan, the man died from acute renal failure.
While the staff were very sorry about the mistake, no steps were taken to prevent it from reoccurring. Electronic drug charts were not introduced at the hospital. Check lists were not introduced into radiology. The hospital continued to use paper drug charts and verbal handovers.
© Wikihospitals 2014