Misread Rx led to nursing home patient's death

  • Article by: PAUL WALSH and BRAD SCHRADE , Star Tribune Staff Writers
  • Updated: November 14, 2011 - 11:29 AM

Mistake shows how hard-to-read prescriptions often lead to tragic results.

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  • Comments

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regionguyOct. 28, 1111:33 AM

That is a LOT of potassium to give a patient on an ongoing basis, and there is no way I would have interpreted that order as being for 80. Given the risk of such a high dose, the staff should have confirmed it with the presecribing physician.

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andrea2315Oct. 28, 1111:58 AM

@regionguy; completely agree. I wouldn't have interpreted that as 80 either.

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barkingshinsOct. 28, 1111:58 AM

Um... are our doctors not aware of these devices called "printers"? Heck, even an antique typewriter would go a loooong way towards eliminating these types of errors. The only item on a doctor's prescription that need not be clearly legible is the doc's own signature.

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mylittleidOct. 28, 1112:01 PM

It might be time for doctors to start using computers instead of writing out their orders long-hand.

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ruddeeOct. 28, 1112:05 PM

Why hasn't the nursing home's board of directors authorized updating their equipment, bringing it up to date electronically?

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glamorousvivOct. 28, 1112:21 PM

It looks confusing enough to me that the doctor should have been contacted.

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amity379Oct. 28, 1112:26 PM

It's very expensive for nursing homes to get electronic medical records. It was a simple error that should have never happened because RNs and LPNs are constantly trained that if you question a prescription, get it confirmed by the doctor...

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louloubelleOct. 28, 1112:27 PM

IT is very sad...this was a classic example of the Swiss Cheese effect...A number or people and things lined up to cause this error to make it from paper to patient....And no one stopped the deadly process. KCL is a deadly drug, and should always be confirmed when the dose is different than it was, higher than normal, or in question. Is there not a drug book available for the nurses to reference? The pharmacist is the drug expert here and should never have dispensed that dose without speaking with the Dr directly. I would clearly read that as 8MEQ, however, it is messy and difficult to make out the entire order...So they need to either upgrade to computers or at least type written notes. And it is always helpful on new orders to read them out loud to the nurse or pharmacist taking them. Sadly medical mistakes happen all the time, this one could have been avoided if someone would have double checked with the Dr. I hope-but am sure that everyone involved will remember their role here, and be diligent in the future and catch future error.

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aanen1Oct. 28, 1112:38 PM

No pharmacist should have filled this handwritten prescription without first checking with the prescribing doctor. If there is ANY doubt whatsoever, it should be checked. Measure twice, cut once. Unfortunately, this isn't sewing, this is someone's life. This was a great big FAIL on the part of all the medical people involved. But most doctors still use prescription pads and hand write prescriptions. Fortunately, mistakes like this aren't very common. But both the pharmacist and the nurses should have questioned it further.

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LewisStrongOct. 28, 1112:52 PM

I agree. that was no zero. and in all probability I was have "clarified" the lasix order too. It appears as though the lasix order was an "8" then "1" was written over the "8". Unfortunately that it takes this type of tragedy to realize the magnitude of human health. What could have been done: 1)Hospital(s) could hire a "medical transcriptionist" to type out all md orders and if the order was unclear that employee could "clarify" the order directly with the discharging doctor. 2) The nursing home who admitted this resident could have consulted one another including the Director of Nursing or Assistant Director of Nursing for correctness. 3) I'm sure there are many other ways to "prevent" this type of error too. thanks for reading and have a good day to all.

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