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A cancer patient who was about to be discharged asked a nurse to watch her husband irrigate her Hickman catheter. As the nurse watched, the husband carefully drew up the correct amount of solution and performed the irrigation properly.
Within seconds, the patient went into cardiac arrest. Despite resuscitative measures, she died.
The nurses discovered that the husband had picked up a vial of potassium chloride instead of heparin. But they couldn't figure out why potassium chloride was on the bedside table. Normally, it was kept in the unit's stock to prepare I.V. admixtures when the pharmacy was closed.
This tragedy needn't have occurred. If the nurse had noticed that the husband hadn't read the container label-or if she'd read it first-she could have prevented the error.
But as with most medication errors, she wasn't the only one to blame. Nurse-managers should keep that in mind when they're reviewing errors at the hospitals where they work. When we search for a lone scapegoat, we may miss other things that contributed to the error. And that means the mistake may occur again.
Let's look at the other factors that contributed to this error. A vial of potassium chloride shouldn't be left on a bedside table, of course. But did it even need to be on the unit? If the hospital couldn't keep the pharmacy's I.V. admixture service open around the clock, perhaps the pharmacist could have provided premixed, commercially available containers of potassium chloride in common I.V. solutions. Or the potassium chloride could have been in a controlled storage area, a step some hospitals are taking.
This hospital used heparin and potassium chloride from the same manufacturer. The vials stocked on the unit were similar in size, shape, and color, as were their labels. The pharmacy could have substituted another brand for either one or used a smaller vial. Heparin, for example, is available in 1`-ml and 5-ml vials and in prefilled syringes.
We can easily think of ways to avert a tragedy after it has happened. Blaming one person or one thing won't fix what's wrong. We have to look at the whole picture and consider changes that could prevent a fatal error.