In our last post, we discussed the latest Leapfrog Hospital Safety Grade Report and the hospitals in Indiana and Illinois receiving grades of D or F in the 2018 national hospital rating system focusing solely on patient deaths caused by medical errors, accidents, injuries and infections.
For details about the report, read our discussion as well as all the online Leapfrog results for over 200 hospitals in Illinois and Indiana in “Indiana and Illinois Hospitals Get Failing Grades in 2018 Safety Report.”
There are all sorts of medical mistakes that cause patient deaths. One of the most common errors involves administration of the wrong medication.
Horror in Tennessee: Example of Hospital Medication Error
Perhaps you have heard about the tragedy in Tennessee, where a woman went into the Vanderbilt University Medical Center for some tests and died after being given the wrong drug.
According to Fox17-Nashville coverage (which cites a report compiled by the Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS)), a 75-year old woman checked into Vanderbilt for testing to determine the reasons for her headaches, loss of vision, and brain swelling.
Versed vs. Vercuronium
She was scheduled for a positron emission tomography (PET) scan. Because she suffered from claustrophobia, her doctor prescribed an anti-anxiety drug to be administered before she had the scan.
He ordered 2 mg of Versed.
When it came time to administer the Versed, the nurse couldn’t find any Versed in the cabinet, so she did a computer search and picked the first drug that came up in the search results.
But it was not Versed. It was Vecuronium. Vecuronium is a drug used in lethal injections in death penalty executions by the State of Tennessee. It paralyzes the body.
The Vanderbilt nurse injected the 75-year-old patient with Vecuronium instead of Versed.
USA Today reports that for thirty minutes after being given the Vercuronium, the elderly woman was left unattended. During that time, she suffered cardiac arrest.
Nurses returned to find her unresponsive. The medical error victim died the next day, after being taken off of a breathing machine.
The grisly death has made the international news. Coverage in Great Britain suggests this woman suffered greatly after being given the wrong drug by the hospital nursing staff. See,”Woman, 75, dies in ‘torturous’ pain after a Tennessee nurse accidentally gave her an EXECUTION drug that caused her lungs to shut down and left her brain dead,” written by Marlene Lenthang and published on December 1, 2018, by the Daily Mail.
Common Medical Error: Wrong Medication Given to Patients
This ghastly accident would be shockingly unacceptable even if it were a rare occurance. However, shock may turn to outrage when compared to reports about how often this type of drug error happens.
According to Harvard research studies cited by Leapfrog, serious hospital medication errors happen to as many as 1 in 4 patients.
The reality that medical mistakes in giving the wrong drugs, or giving the right drug in the wrong dosage, has been known to the medical community for many years.
Over 12 years ago, the Institute of Medicine (IOM) published its report Preventing Medication Errors, confirmed that hospital medication errors were harming over 1,500,000 patients each year in 2006.
Back then, it was recognized that “every hospital patient is probably subjected to at least one medication error every day …” although not all of these were life-threatening or fatal.
The problem has only escalated with time.
HAM Drugs: High Alert Medications Most Likely to Cause Death in Medication Errors
Of particular concern are certain categories of drugs, i.e. “high alert medications” (“HAM”). There are four kinds of drugs in this group:
- Anticoagulants
- Sedatives
- Insulins
- Opioids.
List of High Alert Medications and High Risk Drugs for Serious Medical Error
There are certain kinds of drugs and medications that are inherently more dangerous for medication errors in hospitals. These medications should always be carefully considered before administration to a patient because making a mistake can be deadly.
From the Institute for Safe Medical Practices (ISMP), an independent non-profit and watchdog organization, comes the following October 2018 HAM categories:
- adrenergic agonists, IV (e.g., Epinephrine, phenylephrine, norepinephrine)
- adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol)
- anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine)
- antiarrhythmics, IV (e.g., lidocaine, amiodarone)
- antithrombotic agents, including:
- anticoagulants (e.g., warfarin, low molecular weight heparin, unfractionated heparin)
- direct oral anticoagulants and factor Xa inhibitors (e.g., dabigatran, rivaroxaban, apixaban, edoxaban, betrixaban, fondaparinux)
- direct thrombin inhibitors (e.g., argatroban, bivalirudin, dabigatran)
- glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide)
- thrombolytics (e.g., alteplase, reteplase, tenecteplase)
- cardioplegic solutions
- chemotherapeutic agents, parenteral and oral
- dextrose, hypertonic, 20% or greater
- dialysis solutions, peritoneal and hemodialysis
- epidural and intrathecal medications
- inotropic medications, IV (e.g., digoxin, milrinone)
- insulin, subcutaneous and IV
- liposomal forms of drugs (e.g., liposomal amphotericin B) and conventional counterparts (e.g., amphotericin B desoxycholate)
- moderate sedation agents, IV (e.g., dexmedetomidine, midazolam, LORazepam)
- moderate and minimal sedation agents, oral, for children (e.g., chloral hydrate, midazolam, ketamine [using the parenteral form])
- opioids, including:
- IV
- oral (including liquid concentrates, immediate- and sustained-release formulations)
- transdermal
- neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium)
- parenteral nutrition preparations
- sodium chloride for injection, hypertonic, greater than 0.9% concentration
- sterile water for injection, inhalation and irrigation (excluding pour bottles) in containers of 100 mL or more
- sulfonylurea hypoglycemics, oral (e.g., chlorproPAMIDE, glimepiride, glyBURIDE, glipiZIDE, TOLBUTamide)
Additionally, some drugs are known to be dangerous by their name. These are specific drugs that should always be carefully considered before giving any dosage to a patient because of the high risk of death from medication error.
Feomm ISMP, the October 2018 list of Specific Medications that are known to be high risk include:
- Epinephrine, IM,subcutaneous
- epoprostenol (e.g., Flolan), IV
- insulin U-500 (special emphasis*)
- magnesium sulfate injection
- methotrexate, oral, nononcologic use
- nitroprusside sodium for injection
- opium tincture
- oxytocin, IV
- potassium chloride for injection concentrate
- potassium phosphates injection
- promethazine injection
- vasopressin, IV and intraosseous
Medication Error and Hospital Medical Malpractice
Medication errors are a serious health threat to anyone seeking treatment at a hospital in Indiana or Illinois today.
Medical errors are recognized by the CDC as being the third most common cause of preventable death in this country and as much as 25% of these preventable deaths are due to a patient being the victim of a medication error.
These deadly medical mistakes can involve all sorts of scenarios, from the wrong dosage of a drug, to the wrong drug being given (e.g., the tragic Vanderbilt example, above). Medication errors can also involve a dangerous interaction between medications, or a physician making a mistake in giving instructions or making a diagnosis.
Those who are victims of medication errors and medical mistakes may have claims to assert based upon the medical malpractice laws of Indiana and Illinois. Sadly, all too often these preventable mistakes are causing the untimely death of the patient and a horrible, life-altering reality for their grieving loved ones.
For more, see:
- Medical Error Cause of Patient Death: the Malpractice Epidemic
- National Safety Month: Accidents and Medical Errors Are Killing Too Many People.
Please be careful out there!
