Another Way To Die
Something bad happened at work. We're going to need lawyers for this one.
What happened is that the lab called a nurse and told her that a patient had a critically low magnesium level. The nurse called the doctor and got an order to give the patient magnesium by IV. The IV was given and the patient, a young healthy woman with a minor injury, suddenly died. She could not be revived.
So, what happened? The nurse who spoke to the lab didn't hear the patient's name correctly and thought that it was a different patient who had a critical low value. So, the wrong patient got the magnesium.
The patient who did need the magnesium and didn't get it in a timely manner also had a close call. Given a little more time we could have killed her as well. This is something that could have happened at any hospital. How scary is that?
Written by Melissa on 12:19 AM
Me
Melissa blogging from sunny Santa Clarita, Southern California, United States.
Friends
5 Comments:
When I worked at your hosp we wrote name alert on the board, and the chart if there were 2 patients with similar names. Labs with critical values should also be faxed to the floor. I always had the lab printout and the chart in front of me before I ever called the dr. It sounds like that didn't happen.
The other issue that no one wants to bring up, is when you have a lot of staff with poor english skills miscommunication can occur. The english test for foreign nurses is written and in no way guarantees oral competence. I doubt the lab has any criteria for assessing language competency except filling out the application, and having an lab assistance certificate, which is pretty simple.
My heart is just sinking. This is very scary stuff.
HP,I'm glad that things turned out okay. Hospitals are dangerous places.
Sarah, all lab results now are automatically printed on our printer, which results in such a stack of papers, they tend to get ignored. The critical value would have shown up on the computer within a few minutes of the phone call, but there is no protocol that we must check the results in written form before making an intervention. Hopefully, that will become a rule now.
You're right about the language problem and it's compounded by the fact that Filippino nurses don't even take an English test. It's just assumed that they speak the language. With all of the accents and language challenges, we're always having misunderstandings, some of which are quite funny. The other night I was eating a kiwi and a nurse asked if I was eating a pig. She meant fig.
LMAO @ Pig/fig...too funny! I can relate re philipino and their language, i have a client whose mother is philipino, and her english is average, her accent though is so difficult to understand, i feel so bad i have to keep asking to repeat what she said!
That is soooooo tragic and sad. I bet the nurse is in shock and feels dreadful.
R2Ks, it's scary and it could happen to anyone.
Michelle, the patients and doctors sometimes get so frustrated trying to understand the various accents, that they sometimes turn mean and say things like, "Put someone else on the phone who speaks English." I've thought about keeping a list of misunderstandings to blog about, but I'm not sure that it could be funny without also being mean.
Post a Comment
<< Home