Medication Dose Error Death
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Medication Errors: Working to Improve Medication Safety Share Tweet Linkedin Pin it More sharing medication errors articles options Linkedin Pin it Email Print When Jacquelyn Ley shattered her elbow on the soccer field, her parents set out to find
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her the best care in Minneapolis. "We drove past five other hospitals to get to the one we wanted," says Carol Ley, M.D., an occupational health physician. Her husband, an orthopedic surgeon, made sure Jacquelyn got how to prevent medication errors in nursing the right surgeon. After a successful three-hour surgery to repair the broken bones, Jacquelyn, who was 9 at the time, received the pain medicine morphine through a pump and was hooked up to a heart monitor, breathing monitor, and blood oxygen monitor. Her recovery was going so well that doctors decided to turn off the morphine pump and to forgo regular checks of her vital signs.Carol Ley slept in her daughter's hospital medication error statistics room that night. When she woke up in the middle of the night and checked on her, Jacquelyn was barely breathing. "I called her name, but she wouldn't respond," she says. "I shook her and called for help." The morphine pump hadn't been shut down, but had accidentally been turned up high. The narcotic flooded Jacquelyn's body. She survived the overdose, but it was a close call. "If three more hours had gone by, I don't think Jacquelyn would have survived," Ley says. "Fortunately, I woke up."Ley was pleased with the way the hospital handled the error. "They came right out and said the morphine pump was incorrectly programmed, they told me the steps they were going to take to make sure Jacquelyn was OK, and they also told me what they were going to do to make sure this kind of mistake won't happen again. And that's very important to me." The hospital began using pumps that are easier to use and revamped nurses' training. Ley believes there were many contributors to the error, including the fact that it was Labor Day weekend and there were staff shortages. "It goes to show that this can happen to anyone, anywhere," says Ley, who now chairs the board of the National Patient Safety Foundation.Multiple FactorsSince 19
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DataSetsGEO ProfilesGSSGTRHomoloGeneMedGenMeSHNCBI Web SiteNLM CatalogNucleotideOMIMPMCPopSetProbeProteinProtein ClustersPubChem BioAssayPubChem CompoundPubChem SubstancePubMedPubMed HealthSNPSparcleSRAStructureTaxonomyToolKitToolKitAllToolKitBookToolKitBookghUniGeneSearch termSearch Browse Titles Limits Advanced Help NCBI Bookshelf. A service of the National http://www.ncbi.nlm.nih.gov/books/NBK2656/ Library of Medicine, National Institutes of Health.Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality http://www.cbsnews.com/news/oregon-hospital-medication-error-kills-patient/ (US); 2008 Apr. Patient Safety and Quality: An Evidence-Based Handbook for Nurses.Show detailsHughes RG, editor.Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.ContentsSearch term medication error < PrevNext > Chapter 37Medication Administration SafetyRonda G. Hughes; Mary A. Blegen.Author InformationRonda G. Hughes;1 Mary A. Blegen.21 Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Agency for Healthcare Research and Quality. E-mail: vog.shh.qrha@sehguh.adnor2 Mary A. Blegen, Ph.D., R.N., F.A.A.N., professo r in community health system and director of how to prevent the Center for Patient Safety, School of Nursing, University of California, San Francisco. E-mail: ude.fscu.gnisrun@negelb.yramBackgroundThe Institute of Medicine’s (IOM) first Quality Chasm report, To Err Is Human: Building a Safer Health System,1 stated that medication-related errors (a subset of medical error) were a significant cause of morbidity and mortality; they accounted “for one out of every 131 outpatient deaths, and one out of 854 inpatient deaths”1 (p. 27). Medication errors were estimated to account for more than 7,000 deaths annually.1 Building on this work and previous IOM reports, the IOM put forth a report in 2007 on medication safety, Preventing Medication Errors.2 This report emphasized the importance of severely reducing medication errors, improving communication with patients, continually monitoring for errors, providing clinicians with decision-support and information tools, and improving and standardizing medication labeling and drug-related information.With the growing reliance on medication therapy as the primary intervention for most illnesses, patients receiving medication int
In Join CBSNews.com Sign in with CBSNews.com - Breaking News Video US World Politics Entertainment Health MoneyWatch SciTech Crime Sports Photos More Blogs Battleground The WH Web Shows 60 Overtime Face to Face Resources Mobile Radio Local In Depth CBS News Store CBS/AP December 4, 2014, 6:11 PM Hospital medication error kills patient in Oregon Comment Share Tweet Stumble Email A hospital in Bend, Oregon, says it administered the wrong medication to a patient, causing her death.Loretta Macpherson, 65, died shortly after she was given a paralyzing agent typically used during surgeries instead of an anti-seizure medication, said Dr. Michel Boileau, chief clinical officer for St. Charles Health System.He said Macpherson stopped breathing and suffered cardiac arrest and brain damage.Macpherson came into the ER two days earlier with medication dosage questions after a recent brain surgery.Three employees involved in the error have been placed on paid leave. The organization is conducting an investigation, but doesn't yet know how the error occurred, Boileau said.The investigation is looking at every step of the medication process: from how the medication was ordered from the manufacturer, to how the pharmacy mixed, packaged and labeled the drug, to how it was brought to the nurses and administered to the patient."We're looking for any gaps or weaknesses in the process, or to see if there has been any human error involved," Boileau said.The hospital notified the Deschutes County district attorney, who did not immediately return a call for comment.According to the Bend Bulletin, the doctors determined Macpherson needed an intravenous anti-seizure medication called fosphenytoin, but instead accidentally administered rocuronium, which caused Macpherson to stop breathing and go into cardiac arrest, leading to irreversible brain damage. The hospital took Macpherson off life support Wednesday morning.The patient's son, Mark Macpherson told the newspaper he'd recently moved to closer to care for her. "We didn't get the answer for a couple of days about what had happened, but when they first told us, it was pure anger," he told the pap