79 yr old man dies after nurse gives him execution drug by mistake instead of Pepcid

[undeterred]

Grandfather, 79, dies after nurse gives him execution drug rather than over-the-counter medicine

A 79-year-old man died after a nurse mistakenly gave him a drug used in state executions rather than an over-counter medicine. Richard Smith was admitted to hospital in Miami, Florida, after complaining of stomach pains and shortness of breath. The former teacher was prescribed Pepcid, an over-the-counter antacid, to try and cure the problem.

But nurse Uvo Ologboride picked up a vial of Pancuronium from a locked drug cart and injected it into the former teacher's IV tube. The drug is given to death row inmates being put to death.

It is a muscle relaxant that forms part of the three injections used in state executions. The drug is also used in operating rooms. An investigation by officials at the North Shore Medical Centre found that Mr Smith was left alone for 30 minutes after being given the wrong drug.

His heart stopped and his son Marc arrived at the hospital to be told his father had been given the wrong drug. Mr Smith, a father-of-four, was resuscitated but never recovered, and died weeks later. An investigation into the incident in July 2010 revealed the nurse on duty failed to read the label, failed to scan the medication and failed to scan Mr Smith's patient ID bracelet.



http://www.dailymail.co.uk/news/article-2062897/Richard-Smith-79-dies-nurse-gives-execution-drug-counter-medicine.html

[Liberal_in_LA]

1. wow. Big lawsuit

[undeterred]

3. Really lousy nurse.

“The nurse said the package looked the same”. (And they both start with P)

[Raster]

7. That's an understatement....

"...the nurse on duty failed to read the label, failed to scan the medication and failed to scan Mr Smith's patient ID bracelet."

[LanternWaste]

27. Or overworked...

Or overworked... :shrug:

[TorchTheWitch]

29. they don't look remotely the same

Going by the photo in the article they don't look the least bit the same, and the dangerous one has warnings all over it. I think that's why it also has the red cap.

I'm having a very hard time seeing that this was an accident.

[TheWraith]

17. It's a lot more common than you'd think.

This case is "newsworthy" because it's a drug used in executions. But medical mistakes kill hundreds of thousands of people a year in the US, including many from getting the wrong drug.

[bigwillq]

2. How sad.

:(

[Desertrose]

5. Yeah, I'll say. Makes me want to cry.

Poor guy....poor family. sigh. So sad.
:(

[LongTomH]

4. But we've got the best health care system in the world!

:sarcasm: Double dose of sarcasm :sarcasm:

[theophilus]

6. Remember! Tuesday is Soylent Green day. n/t

[Horse with no Name]

8. What a horrible way to die.

Poor guy. IF you can imagine a pillow over your face and being tied down at the same time....this drug is merciless in that it doesn't cloud your thinking--you know exactly what is happening and can't do anything about it.

That being said...why the fuck would you bypass the medication scan???

I've worked with some African nurses before and sadly, there is a HUGE language barrier. I'm sure this played into it as well.:(

[unblock]

9. hey, at least it cured his stomach pains.

:hide:



seriously, i'm getting a medic alert bracelet -- "SEVERE ALLERGY -- DO NOT ADMINISTER PANCURONIUM".

nah, someone would probably just misread that give it to me anyway....

[Horse with no Name]

10. They'll just label you as "drug seeking"!

:rofl:

[Taverner]

11. Wait - why do they keep that stuff in hospitals?

As far as I know, the only place they should be keeping execution drugs is on Death Row at a prison.

[TorchTheWitch]

13. The whole thing sounds too weird to me

I have a very hard time believing this was an accident.

As I understand it the drug is also used as part of anesthesia which is why a hospital would have it. I don't see that any hospital would have it somewhere that's as easily accessible as Pepcid nor in the same place, and there's something very strange about her not scanning it nor his ID bracelet.

[Taverner]

16. True. Most hospitals lock the med cabinet down so tight, it takes several people to unlock it.

Hell, UCSF's medical cabinet is 100% robotic

[TorchTheWitch]

22. when I worked as a nurses aide back in the early '80s

the protocol for getting the drugs from the drug room on the floor onto the cart and administered to the patients was so stringent and so many keys and doors were needed there was just no way one person could make such a "mistake". Two nurses were always required to load the cart in the drug room so nothing that shouldn't have been on the cart could have been even by mistake. They had to call out each item out loud to the other and check it off and sign off on it, etc.

At the time I thought it was unnecessarily elaborate, but when I got older and wiser I realized it was a good thing they did it so carefully.

I just don't see this hospital having such a lax system or how one nurse could have made such a "mistake"... and the not scanning the drug nor the patient ID bracelet just looks very suspicious.

[Initech]

18. Maybe I've seen one detective show too many but it's weird to me too.

[slackmaster]

15. Sensationalistic Daily Mail headline is sensationalistic

A quick Web search will show you that the drug has other legitimate uses in medicine.

[Horse with no Name]

19. It is also used in sedation for ventilated patients

Necessary drug...but everyone I have ever worked with was very AWARE that that particular drug was on the floor...not to mention that it has warnings on it...and practiced extreme caution in its presence.



I am telling you my bet is on the language barrier...as well as shortcutting the method in place to prevent errors.:(

[nadinbrzezinski]

20. Because it is a muscle relaxant

used when you bring in a code trauma who needs to be intubated.

The nurse took it out of a locked medical cart. Pepcid IS NOT locked... this, I hate to say it, was not a mistake.

But if you must ask, we used a cousin of that to precisely do that, paralyze patients to entubate them

These agents are fine... when properly used.

[Blasphemer]

24. I was wondering about that

I can understand picking up the wrong drug by mistake but a locked vs. unlocked drug is far more suspicious. I hope this is thoroughly investigated.

[AnneD]

12. As a Nurse...

my heart goes out to both parties involved. Most Nurses never go in to cause harm and you can't imagine the grief when it happens, even if it turned out to be an innocent error.

But my next question is ...Why the hell is that medication in the cart. I did a quick check and it is used for light anesthesia and for vent patients. So unless he was on a vent, I can't see what it is doing on the cart in the first place.

I say this because one time I went to get a med out of one of those smart carts. Cart was loaded with the wrong med. Yeah, it was pharmacy error but guess who gets the blame.

I need more facts, but in this day and given the climate of the hospitals.....I hope another accident can be avoided.

[MedicalAdmin]

14. Nurses, like many service professionals...

are being mercilessly squeezed in time and finances. This is not an excuse for doing safety scans, but when staff is perpetually over rushed and over worked, mistakes happen.


THis is the very definition of tragedy.

[AnneD]

21. ITA....

and I didn't even mention that factor. The story is out of a UK paper and I do know that drugs use varies country to country. I don't know if it was in a hospital there(had trouble with link). Even so, Nurses face a squeeze no matter where they are. Here the squeeze is very bad. I have totally gotten out of bedside Nursing. I would rater have a root canal sans anesthesia-very hospitals meet my personal Nursing standards.

[MedicalAdmin]

30. Anne.

Thanks for giving us your input. It is good to hear from someone who has been there and done that.

Even with the differences in countries, there is still no reason for the mess up. Every person from the physician to the pharmacist to the person who loaded the cart to the nurse to any other person who saw what was happening or should have had a "check" didn't catch it. And that is a tragedy.

Here is my story. I know a hospital administrator in Canada who, as a rule, won't hire nurses from the States because "they don't know how to slow down and get it right." Admittedly this woman was not the easiest person to get along with, but I wonder if the system in the US is detrimental to nurse efficiency. What is your opinion?

[AnneD]

32. Although I have been off the floor for a while....

the current system here in the states is to the detriment of Nursing. It would take a while to change the culture to one of slow down and get it right. If you do slow down to get it right, you are rewarded with too much charting after your 12 hr shift. And that is another thing, I loathe 12 hour shifts. I know me and my concentration goes down after 10 hours. I try to take time to get it right but frequently have to carry the portable phone during my med pass to answer calls because there was no secretary. How is that for a disaster waiting to happen? :wow:

I would frequently be in the middle of a med pass and people would interrupt me for things like... say complain that their family members food was not warm, or they needed an extra tray, or juice or the food was not what they wanted. This would put me behind in distributing the meds not to mention make me loose track of the meds that I was preparing. This was done from a mobile heavy cart that was not so mobile that I was lugging down the hall.

The two most common med errors that cause death are from Heprin and Insulin. You are far more likely die from the misapplication of those very common drugs than what the gentleman died from. They always recommend having a second Nurse to check off on it but frankly, unless I could pull another Nurse out of my butt, that was unlikely to happen for me.

I am close to retiring and once I hang up these Crocs, that is it. I don't care if it is a disaster and the federal marshals come to my house and force me to the hospital....I will face a firing squad first. I heard from Nurses first hand what happen in NOLA after Katrina. I'll be getting the hell out of Dodge. When I signed up to be a Nurse, I didn't sign up for this craziness.

[undeterred]

31. It happened in a Florida hospital.

Don't states require nurses to re-license every year? I just can't see a nurse giving a patient this drug for stomach pain.

[mainer]

23. This is an O.R. drug! Shouldn't be on the ward, #!.

And Pepcid is given by mouth, not IV.

It's hard to avoid the conclusion that this nurse was intent on murder.

[TorchTheWitch]

26. Pepcid is available as an injection for IV use

I guess for those people that can't take it orally for whatever reason.

http://www.drugs.com/pro/pepcid-injection.html

[undeterred]

25. It makes the hospital experience very scary for patients...

I was working at U of Chicago Hospitals years ago when they had a chemotherapy mistake with a testicular cancer patient. It was a new drug and the tired resident wrote the order for 10x more than the dose was supposed to be. Nobody caught the mistake before the wrong dose was administered by a nurse. The patient became sicker, the mistake was caught, and they quickly realized it was a fatal dose. They had to tell him he was going to die in a couple of days. He was in his 30s.

Three different people could have caught the error, but none of them did. This was a teaching hospital, and a patient came in with a curable form of cancer and was essentially killed. It led to a major review of procedures on all levels.

Staff do take it very personally when something like this happens.

[AnneD]

34. I remember reading about that.....

that was so tragic. There but by the grace of God....

Folks expect perfection but we are flawed humans. It is a miracle we don't have more mistakes.

[WildNovember]

28. That's a huge "mistake". Pepcid isn't kept under lock. She had to go out of her way to make

that "mistake".

[AnneD]

33. As I said earlier...

there are some missing pieces to this puzzle. Working in the hospitle has given me a "there by the grace of God" attitude. Until I know more I have great sympathy for both sides and hope the situation is reviewed and lessons learned.