Worst Patient Care Errors

[Just Plain Ruff]

yeah I agree

We brought my grandfather in to the ER for an infection. He was one step away from hospice and gave the nurses his DNR.

The nurse walked away and didn't even listen to the rest of the story.

She came back and I asked why she walked away and she said that "He's a DNR" I blew a gasket and didn't even go to her supervisor. I went directly to the Director of Nursing.

I also came back to the ER and when she walked back in to continue to take care of my grandfather I had already prepped my Grandma and I told the nurse I wanted a new nurse. someone with a more caring attitude.

She said that she was who we got. I told her unacceptable. She walked out again right into the loving arms of her Director of Nursing and the nurse manager.

We got a new nurse and we got a letter of apology from the hospital.

It's inexcusable for a nurse or healthcare provider to be so nonchalant. My grandfather needed care, the DNR said no resus not NO treatment.

In the end he succumbed to his illness about 8 weeks later but I was able to say goodbye and he died in the hospice facility where he was kept comfortable and cared for very well.

[DwayneEMTP]

As an RRT I had to give a deposition for a Combitube vs Larynx on a 20 y/o who just had a little too much alcohol to drink and was brought to the ED by ALS. It was placed by a Paramedic who thought the Combitube would prevent aspiration better if the patient vomited. (??!!?) The poor kid will not be using his own larynx to speak again.

I'm sure the Floridians remember this fairly recent incident.

Florida Woman: Paramedic's Error Caused Loss of Arm

http://www.emsresponder.com/article/articl...p;siteSection=1

Rebecca Mahoney, Sentinel Staff Writer

Orlando Sentinel (Florida)

SOUTH DAYTONA -- A violent stomachache prompted 84-year-old Marie Caschetta to call 911 in January 2006.

She expected to end up in a doctor's care. Instead, according to a lawsuit, she wound up losing most of her right arm.

Caschetta says a paramedic with Volusia County's ambulance service, EVAC, wrongly gave her a drug that can cause gangrene when improperly injected.

The South Daytona woman has since undergone three amputations, each time losing a different portion of her right arm, and she may face a fourth amputation that would take her elbow.

"I lost my whole life that day," said Caschetta, who is suing for an undisclosed amount of money. "I went in for a tummy-ache and came out without a hand. I'm an invalid."

The lawyer representing EVAC, Barbara Flanagan, declined to comment on the case. According to court records, however, Flanagan has argued that Volusia County, not EVAC, is legally responsible because its medical director sets the protocol for ambulance responses. County attorney Dan Eckert did not immediately return a call seeking comment Monday.

At issue is the paramedic's use of a medication called Phenergan or promethazine, used to quell nausea. If it is accidentally injected into an artery instead of a vein or a muscle, it can make arteries shut down and cause gangrene.

You know, I've only seen one person put and IV into an artery. An old man, veins like ropes all over his arms. I can see how you can possibly hit the artery, but how do you not know after? There was blood all over the floor, as the medic student believed he wasn't occluding properly, but when the line was attached, the blood ran back into the bag that was hanging about 3' above the patient....Even I knew that seemed a little hinky!

Does this really happen that often?

Dwayne

[theotherphil]

You know, I've only seen one person put and IV into an artery. An old man, veins like ropes all over his arms. I can see how you can possibly hit the artery, but how do you not know after? There was blood all over the floor, as the medic student believed he wasn't occluding properly, but when the line was attached, the blood ran back into the bag that was hanging about 3' above the patient....Even I knew that seemed a little hinky!

Does this really happen that often?

Dwayne

I've also seen it once done by a Dr into the brachial artery. It did indeed travel back up the line and into the bag pretty quickly :shock:

[zzyzx]

Some of the best stories I've heard from where I work....

A crew picks up a frequent flyer homeless patient who is slightly altered and having difficulty breathing. They've had this guy before and know he has asthma, so they give him a breathing Tx. They assume he's altered cause he's drunk again. They transport to the local hospital. Hours later the staff at this hospital realizes the patient has suffered major trauma. It turns out he was hit by a vehicle. He is transferred to the trauma center but dies there. The medic lost his job.

Another story...a guy get's kicked out of a gay bar. The patient may or may not have been altered (depending on who you believe). The medic puts the patient in the back with his EMT and takes him to the ER. They tell the staff that he's just drunk. He's put on a hall bed and not well monitored. Much later they find him to be unresponsive with a very low blood sugar. It turns out the patient is related to one of the ER nurses, who raises hell. Lawsuits follow. The medic claims that the patient wasn't altered when he saw him, just drunk. He says that it's the hospital's fault for not watching the patient, and that his blood sugar dropped while he was left there. However, the EMT had written on his paperwork that the patient had a GCS of 4/6/4. The medic lost his job.

[captainstandup]

However, the EMT had written on his paperwork that the patient had a GCS of 4/6/4. The medic lost his job.

The Paramedic was too stupid to work anyway, why was an EMT attending to and documenting the patient care report for a patient with an altered LOC? In a manner of speaking the Medic abandoned the patient or was, at minimum, negligent by failing to attend during transport. Of course i suppose it is possible it was a three person crew or perhaps the medic "just let the EMT document the call"

[johnrsemtp]

EMT B on a medic truck spiked a 500mL IV bag of Lidocaine, ran in about 300mL bolus by the time they got to the ED. Medic couldn't figure out why he got in more trouble than his 'stupid' EMT.

RN in ED gave a 3 y/o with an allergic reaction 1mg Epi 1:1,000; "if they were only supposed to get 0.15mg, it should come that way".

same nurse, same shift gave Ketorlac instead of Ketamine, IM for a hip reduction.

told for both times: don't do it again.

[firedoc5]

I've also seen it once done by a Dr into the brachial artery. It did indeed travel back up the line and into the bag pretty quickly :shock:

We were called to the dialysis center to transport someone having some sort of reaction. The nurse was standing next to the guy squeezing an IV bag of NS. :shock: They had the IV in the shunt and she was squeezing it to prevent the back up. WHY??? even have it? :roll: To this day I was never given a ligit answer. As far as I know there were no meds being given.

[captainstandup]

This brings up what is likely a much broader discussion regarding the risk vs benefit of many medications. Phenergan or promethazine has been on a very short list of nasty meds for a while now. I have been given this medication improperly and suffered with 8 months of phlebitis in my right arm. I have witnessed nurses and medics administer phenergan without diluting it then a half hearted attempt at flushing the line.

I personally NEVER, EVER administer this medication without first making darn sure the line is patent and there is no conceivable evidence of infiltration or "leaking" @ the IV site. I then thoroughly mix the promethazine in no less than 20 ml of .9% NaCL and administer slowly, followed by flushing with at least 20 ml of .9% NaCL.

With all this said I try to avoid promethazine and instead administer Zofran and if needed Ativan which seems to be much better tolerated and more effective on really sick patients.

[croaker260]

Know of a situation, Pre-HIPAA, somewhere else other than here, where a medic went on a trauma code. The patient was a know diabetic coincidentally.

So the medic decided to just give him 25 GM D50 in addition to the epi, etc.

The real problem? Since he didnt have a line, he gave it down the tube.

Again this was DECADES ago, and I dont remember what city, state, or country this was in.

[ksmedic202]

Right after I had started my first job in full-time EMS, I got my first anaphylaxis call. Brand new medic( I hadn't had my cert very long, no excuse though). Our protocol was .3mg-.5mg of 1:1000 Epi SQ followed by .3mg-.5mg of 1:10000 Epi SQ if no relief. Well, I gave the first dose, and then gave the follow up dose of, yep you guessed it, 1:1000. No harm to the patient, but I was sick to my stomach. Recieved a verbal counsiling from my supervisor but no other penalty. Damn well better believe that I spend a lot of time reviewing my protocols even now, no matter how well I think I know them.