Did anyone hear about this mistake?

[Loree]

Story

How sad is that?

[MikenJulie]

Absolutely disturbing, I don't know how else to comment to that article. My condolences to the familes.

[Beachnutt]

The pharmacy stocked the wrong dose and is partly at fault but more so the nurses who did not double check the doses before administering them. What an awful thing to have happen. And three times, I just do not understand.

[cmsitaly]

This is so sad, it has been alloover the news here. I feel horrible for everyone involved-babies families, nurse and pharm tech. Even though it was their fault...I can't imagine the guilt.

[Seakony]

I think Evelyn told me that the 2nd or third leading cause of death was Hospital errors....can't remember which one it was..heck, it could have been 4th.

[Jo]

Horrible indeed.
And unfortunately it has to be admitted that such errors happen more often than we want to know- usually not with a deadly outcome though, so they don't get covered or even suspected.
We recently had two cases of babies dying due to mistakes in hospitals here in Hamburg- in one case the dose of kalium administered by a nurse was too high, in another a perfusor with glucose wasn't stopped in time and the child died.
In both cases the errors were simply due to lack of checking back etc..
It is absolutely unbearable and horrible when such things happen- but apart from giving the ones responsible a thorough "beating" it should also be a point which makes us start thinking about prevention.
Yes- in some cases it's just that the person doing their job is in the clouds with their head as they are just human, which shouldn't happen.
In others it's due to stress, being overworked, not enough personell, not enough backchecking- and those can be worked on.
Example: the second case in Hamburg went like this- the child had a normal surgery, was doing good- but had low glucose levels after it. So the anestesiologist decided to administer glucose. On that unit they only had 40% glucose- a very high dose- and as the doc was stressed and didn't have time it didn't cross her mind that the next unit may have lower dose glucose.
Instead she decided to give the high dose but just for a certain amount of time (which leads to the same result- mathematically correct so to speak). She started a perfusor with the med and told the nurses to turn it off after the amount of time......................then left the unit as she was called to an emergency.
Right after the emergency was over she went back to the child to check- and the perfusor had not been stopped (which shows another mistake she made- she could have programmed a stopping time in, which she didn't)...............so the child had had the full dose of glucose, which lead to brainswelling and death in the end.
All of this could have gone well had the doc taken more precautions than she did and had the nurses checked back- in 99% of the cases a setup like this will go well, in this case it didn't.
In reports it showed that stress involved and low key of personell were the leading factors in this...................................
So, while this is tragic beyond belief, and while for sure responsibility lies on the shoulders of those who failed (and it will lie there heavily!!) we also have to see the signals this sends out.

[Jo]

I think Evelyn told me that the 2nd or third leading cause of death was Hospital errors....can't remember which one it was..heck, it could have been 4th.
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I believe btw. that this referrs to "death in hospital" (which doesn't make it better.....) and is actually outnumbered by deaths caused by infections acquired in hospitals (nosocomial infections). So as much as it is sad nowadays that patients get less and less time to recover in a hospital due to monetary issues (at least here in Germany, thanks to the Australian imported DRGs......gnnnnn) it has it's good sides as well- less time in the hospital, less chance to get an infection.