Wrong Meds, Again! “It was horrible,” said the distraught client. “No matter how many times I provided the information, no one l
istened to me. And they obviously didn’t listen to each other either, because they used the wrong meds . . . again.” “Okay, calm down. Now tell me what happened from the beginning,” urged Melanie Torrent, the Quality Assurance Manager for Hope Memorial Hospital. “I got a call at work saying my father was being taken to the hospital from the nursing home. The nursing home always sends a list of medications with the ambulance, but when I got to the emergency room, they were asking my dad what medications he was taking. Of course my dad told them he wasn’t taking any medications and they believed him! He’s sent to the emergency room from a nursing home and they decide it’s reasonable for him not to be on any medications . . . so of course I corrected him and told them to find the medication list. I don’t know whether the ambulance driver forgot to bring in the list, or gave it to the wrong person, or what, but they couldn’t find it. My dad must be on 12 different medications so I wasn’t sure I could remember them correctly. I called the nursing home and we went over the list with them, and then I gave the handwritten list to the nursing station. In the meantime, my dad was admitted to the hospital and moved to a hospital room. Again, a nurse came in with a computer and asked me to tell them what meds he was talking. I tried to tell them that the emergency room had the list, but she said it would be the next morning before the list got updated online. Nevertheless, the nurse called down to the emergency room and was faxed up the list of medications. Only the fax was unreadable, so they came back to me. It was a few hours before his next meds were due, so I drove over to the nursing home, had them make several legible copies of the meds list and drove back to the hospital. I gave the nurse the list, kept one for myself and posted the other on the bulletin board in my dad’s room. The nurse thanked me and said she’d take care of it at the end of her shift. After a long night at the hospital, I woke up the next morning to see my dad hallucinating. I knew immediately what had happened—there’s a certain drug that he has this reaction to. I ran down to the nurse’s station and had her look up the medications he had been given. Sure enough, it was there, along with several other medications he should no longer be taking. Turns out, the list was from two years ago when he had last been admitted to the hospital! How could they have made that kind of mistake—using data from two years ago?” “That is something we’ll look into. More importantly, has your father been taken off the drug?” “Yes.” “And has the medication list been corrected?” “Yes.” “And how is he doing today?” “Fine today, but it could have been more serious and I think you should look into changing your procedures so this doesn’t happen again . . .” “I appreciate you bringing this to my attention. I will speak to the persons involved and I assure you this will not happen again. Hope Memorial prides itself on being a caring and responsible health care provider. Now if you’ll excuse me, I have another client to see . . .” 1. Trace the path of the medication list and denote possible failure points. Construct a process flowchart of the existing process and create a new chart of an improved process. 2. Was the medication error a failure of individuals or a failure of the process? Explain. 3. Think about the different settings, the ambulance, the emergency room, the hospital room, and the nurse’s station. How is data handled in each scenario? Can the process of recording information be changed so that every one is using the same data? How can the accuracy of the data be assured? 4. Given Melanie’s reaction, do you think this error will happen again? Why or why not?
