Worst Patient Care Errors

[firedoc5]

This is a topic that can go on and on.

Saw a medic in the field defib someone on the wrong side. Patient died later of liver damage.

An ER nurse attempting to hook up a foley catheter to suction. Got her stopped just in time.

X-Ray tech. unplugged ventilator in ICU, TWICE in two days. Can you say fired?

Radio call up that "patient had good neuro deficits". Same medic spelled broke "b.r.o.c.k.".

ACLS student couldn't identify a third-degree block, said to defib until got a rhythm that he knew and knew how to treat. We started laughing, until the guy said he was serious. Can you say flunked?

In the early '80's had a ER doc not know what MAST were, so he ordered them "cut off".

[firemedic05]

Dispatched to a general "sick case" at nursing home. Arrived at desk and asked quick reason why the patient was going to ER. The "maybe" RN, "maybe" LPN presented very nervous and stated that she had never "sent someone out" and gave a very vauge report. This prompted more questions, to which I got the nurse from the prior shift made the call. Then asked if the patient was a full code or DNR and paperwork. In front of my partner, the nurse stated Yes, she is a full code. Arrive in room, to patient with mouth and eyes wide open but unresponsive, even to sternal rub. En route, called ER and told them what I had and began treatment for coma of unknown origin. O2, IV, Monitor, Pulse Ox, then Narcan, Thiamine, and blood sugar presented high, in the 400,s. According to my protocol, we infuse a liter when sugar is over 300. Lungs were clear and reassessed en route. Don't remember exact heart rate but sinus tach with no ectopy or obvious arrythmia. While arriving at ER, fairly close run, I find in the 12th piece of paper a DNR paper. Upon entering room, immediately told ER nurses and docs. This was like 0200 hours, so they were none to happy with me. Talked to my medical control doc about it and he told me that he absolved me of all wrong doing. I have to say, though, I felt worse for treating then making a med error or not having done a treatment. I really beat myself up for it, for a while. Thinking I should have looked through all the paperwork. The ER doc called the POA and they said that they were told that the patients blood sugar was just to high and that is why they were going to ER. By the way, the DNR was specific - no hospitalization, no IV's, no nothing basically. Not really, a horrible mistake but made me feel like I had "messed up". Not a good feeling and I can only imagine what a really big error must make you feel like.

[VentMedic]

X-Ray tech. unplugged ventilator in ICU, TWICE in two days. Can you say fired?

Hopefully not fired. This is a very common occurrence in the ICUs made by physicians, nurses or anybody using any type of electrical technology. RTs complain on their forums and at national meetings that they are not able to get the manufacturers to make the electrical plug a different color. There are some regulations in the electrical industry that prohibits that. Only extension cords can be differently colored. Luckily most ventilators have loud alarms when unplugged. Unluckily, many ventilators will go through a self test which can take them up to a minute to start ventilating again.

The true error comes when you don't recognize what you did and/or the people who are supposed to recognize a high alert alarm do not respond.

With medical errors, the worst ones involving loss of life are handled swiftly amongst the receiving hospital, EMS agency and/or governmental agency, the lawyers, the insurance companies and the pt's family. The healthcare workers themselves are told not to talk about the patient or anything concerning the patient amongst their peers. Violation of that can mean serious consequences for their job. The media and the public will not usually hear of these incidents. In the hosptial the incidents are reported as a sentinel event to the Federal agencies monitoring hospitals.

Government and municipal entities also have a different system for handling medical lawsuits involving their agencies for they do have some protection. Thus, those "mishaps" may be squashed quickly by the court system.

I have seen many medical errors throughout the years and will only discuss incidents to those that are required to know or for internal teaching purposes. This is to protect the patient, family members and the person(s) involved. It is a tough time for all when someone you know may have made a fatal error.

Of course, I too a guilty of posting other peoples' incidents that make the news that I, my agency or hospital are not involved in. I figure it is in the news now and can be used as an awareness that errors can happen.

I did mention the combitube incident because I have a firm stance on proper education and training on medical devices for all levels including the Paramedic even if the device is somethings represented as BLS. The consequences can be very bad for the pt and a bad career breaker for the EMS provider.

[MedicRN]

...I have to say, though, I felt worse for treating then making a med error or not having done a treatment....By the way, the DNR was specific - no hospitalization, no IV's, no nothing basically....

Let me get this right.... You feel bad about TREATING a DNR patient (DNR wording aside)? What would you have done if you knew this patient was a 'run-of-the-mill' DNR?

[Just Plain Ruff]

OK I have to address something.

Why do medics and emts get so bent out of shape transporting a patient with a DNR.

DNR does not me do not treat or it would be called a DNT

You treat the patient and not the DNR. If the patient has a DNR they have made specific directions to not be coded but a DNR does not have any place in specifying out treatment requests.

For that you get a living will or a power of Attorney for Healthcare.

DNR means NO CODE not NO TREAT

We need to get our terminology straightened out or we just look like idiots.

[ninjaemtff]

Ruff...I couldn't have said it better myself.

[firedoc5]

Hopefully not fired. This is a very common occurrence in the ICUs made by physicians, nurses or anybody using any type of electrical technology.

Yep, the second time the doc was standing right there. They thought he was going to hit her. But evidently she was on thin ice for more reasons that just that incident.

[VentMedic]

Yep, the second time the doc was standing right there. They thought he was going to hit her. But evidently she was on thin ice for more reasons that just that incident.

That's too bad when someone loses a job because other regulations prevent an industry from making equipment safer to prevent such errors.

Hopefully the doctor was able to channel his need to hit an employee to someone who needed to bag the patient until the ventilator reset to ventilating. I've had way too many doctors, some repeat offenders, unplug the ventilator when they were setting up for a procedure but I have not felt like hitting them. That type of anger does no one any good. You deal with it for the pt's sake and educate the person even if you have to do it over and over. Possibly being restricted from the critical care area for awhile if possibe would be a better option for the Radiology Technician. Or, a nurse, RRT or physician could be present to assist maneuvering through the equipment would be an easier and safer option.

[MSDeltaFlt]

Where do I start? Oh, here we go:

1. Keep your kit with you. Don't take a dump without it.

2. Almost as bad; make sure you have your stretcher.

3. Don't go on a code without your cotton-pickin' monitor.

4. Make sure your truck is in Park BEFORE you get out.

5. Learn the generic names of your drugs. Dexamethasone is NOT Benadryl.

6. Do NOT get frequent NIBP's on the same arm that has an A-line. NIBP's go on the OTHER arm.

7. Amiodarone post cardiopulmonary arrest should be given through a PUMP, not SLOW IVP. You will resume CPR.

8. If you have a pt on a NTG, and you need to change pumps. Clamp the line off! CPR will ensieu.

9. If you're in a code and the doc says to bag faster, let the pt exhale after each breath. Massive iatragenic subq air is not a good thing. At least give the family an option as to an open or closed casket funeral.

10. If you have to RSI a pt, make sure you restocked that AMBU bag. Failure is not an option.

11. Intubated ground transfers that are extubation risks and on sedation drips: add a paralytic drip or reserve your right to refuse to take the trip. "Oh %$#@!" won't fix an extubation in BFE nor will it prevent a pt from crashing on your ass.

[firemedic05]

I get aggravated about the DNR thing, too. If I would have intubated the patient, though, that would have been an error and mainly just mad that I am imperfect. Which, I was sure I was perfect. That is sarcasm by the way!!!! Just felt like I made a mistake and that is not a good feeling. I know that a DNR is not a Do Not Treat - nothing makes me more PO'd than when I bring a patient to the ER and they walk away after being shown DNR papers.