When Human Error is Fatal

I had just returned home from visiting my sister in the hospital when I read the article.  Two babies have died as a result of receiving adult doses of Heparin.  The drug is given to premature babies to prevent blood clots that could clog  IV drug tubes.

A quote from the hospital:  "This was human error - that's all."  And they offered an apology  to the grieving parents.

That's ALL?  My God, is that supposed to be reassuring or exonerating? 

Why, oh why WHY were the dosages not checked?  If someone is giving me or someone I love medication, I want them to CHECK what it is they're giving and make sure it's correct and accurate.

I left my sister at the hospital this evening after talking with her physician there.  A week ago tonight, she fell on her face because she was not strapped into her wheelchair.  For several days, she had been dizzy and a little bit disoriented.  She was sent to the ER at that time - she has a possible nasal fracture that is not displaced, lots of bruises on her head and two black eyes.

Last Wednesday, she was back in the ER because of altered mental status.  I thought - maybe she's having a bout with post-concussion syndrome.  Her cardiac enzymes were off the charts, yet she wasn't having chest pain.

New labs showed her Dilantin levels were three times what they should have been.  The physician at the hospital made a call to the nursing home's medical staff to ask who had raised her dosage.  The doctor there denied it.

As a matter of fact, her labs had been drawn two weeks ago and her Dilantin levels were normal. They were read to the nursing home doctor over the phone and he said - Excellent!  Continue her on 100 mg 3 times a day.  Well, here's where human error came into play. The telephone order was transcribed into the chart as 300 mg 3 times a day, and that's what she got for more than a week.

She wasn't having a heart attack - the medication was screwing up her enzymes and everything else. She is suffering from Dilantin toxicity.

It was a clerical error, the hospital physician told me.  Somebody owes her a BIG apology.

Why on earth was that not noticed?  Why would you increase a seizure medication in a patient whose seizures are controlled on the present dosage?  Why was the telephone order not read back to the doctor for confirmation?

He also said - the GOOD thing about errors of this nature is that they are a wake up call.  Policy and procedure will be reviewed.

Apology. I could spit that word in the faces of all who offer that to the parents of babies who received adult doses of medication and died, and those who overmedicated my sister and COULD have killed her.

Another person in the room said in a quiet voice to the physician who seemed to be glossing over the mistake...

A slip of the pen can kill a person.

Apology my ass.