May 6, 2019 – Mistakes

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Anchor lead: What can we learn from the prosecution of a nurse for a medication error? Elizabeth Tracey reports

Two medicines with names beginning with the same letter can be dispensed on an inpatient unit, one of them for anxiety and another for paralyzing muscles. A nurse dispenses the wrong medicine, resulting in the patient’s death. This real life story has resulted in criminal prosecution of the nurse, and Patricia Davidson, dean of the Johns Hopkins School of Nursing, says there are many lessons here.

Davidson: Just not putting drugs alphabetically in a dispensing machine. We think of how diligent we are about prescription of narcotics and how there’s countersigning mechanisms so I think in that case there’s a systems-based issue. There’s also this issue of disclosure. A very punitive stance taken on that nurse. We all know that with mistakes there are some disciplinary actions but I think no health professional walking into work has any intention of doing anything but good for people.  :34

At Johns Hopkins, I’m Elizabeth Tracey.