ethical question

[automaton]

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How bad is it to give a bowel prep to the wrong person if they had similar names and were sharing the same room? Is that unprofessional or an honest mistake... if you don't admit to the error is that ok b/c what's done is done?

 

[Pox in a box]

How bad is it to give a bowel prep to the wrong person if they had similar names and were sharing the same room? Is that unprofessional or an honest mistake... if you don't admit to the error is that ok b/c what's done is done?

You have to admit the error.

 

[doc05]

you have to be pretty stupid to do this.

 

[P Diddy]

How bad is it to give a bowel prep to the wrong person if they had similar names and were sharing the same room? Is that unprofessional or an honest mistake... if you don't admit to the error is that ok b/c what's done is done?

what's done may be done, but the typical penalty for this mistake is your very own, self-administered Fleet's followed by 12L of golytely. your residency director then drives you 2 hours away from the nearest restroom and drops you there on your off day. yes, you can use your sock.

 

[Bobblehead]

This is really a sticky situation. It's these types of things that can lead to sentinel events. There had to be a sequence of errors to lead to a patient getting the wrongly prescribed medication. That sequence involves you identifying the wrong person for the wrong medication, the pharmacy issuing that medication and the nurse administering it. Sometimes the patient can catch it and you get a near miss. But this is definitely something that SHOULD be reported. You should discuss the situation with the primary care team (i.e. the attending should know before anyone else) and then notify risk management of the situation as well as the program director/division head.

The person responsible for the order and ideally the person that has the best rapport with the patient should then explain all of the facts to the patient, explaining a mistake has happened, apologizing for the mistake, the consequences of that mistake (likely not much besides a bunch of trips to the bathroom in the case of a bowel prep), and how you're planning on ensuring this doesn't happen again (i.e. this is where the matter should be reported to the hospital to ensure there's better verification of medications with bar coding the medications and patient identification, etc.).

Above all else in a case like this it's best not to cover things up. People are smart and generally forgiving if no harm is done. But people get very pissed off if they're lied to. Mistakes happen and most people, if no harm is done, will grumble but eventually they'll get over it. But if the patient/family feels like something is covered up you can believe that the s*** will DEFINITELY hit the fan. Multiple studies (which I'm too tired to reference at this moment) back this up.

 

[electra]

Never, Never, Never Hide things like this........Bobblehead is exactly right.

A mistake like this is a combination of problems (i.e., you needed a name alert on the room door and on the chart), how was it given to the wrong person (did they change beds for some reason?) and was there any harm done (your patient will always wonder if they find out from someone else.)

Welcome to the hospital.

This is really a sticky situation. It's these types of things that can lead to sentinel events. There had to be a sequence of errors to lead to a patient getting the wrongly prescribed medication. That sequence involves you identifying the wrong person for the wrong medication, the pharmacy issuing that medication and the nurse administering it. Sometimes the patient can catch it and you get a near miss. But this is definitely something that SHOULD be reported. You should discuss the situation with the primary care team (i.e. the attending should know before anyone else) and then notify risk management of the situation as well as the program director/division head.

The person responsible for the order and ideally the person that has the best rapport with the patient should then explain all of the facts to the patient, explaining a mistake has happened, apologizing for the mistake, the consequences of that mistake (likely not much besides a bunch of trips to the bathroom in the case of a bowel prep), and how you're planning on ensuring this doesn't happen again (i.e. this is where the matter should be reported to the hospital to ensure there's better verification of medications with bar coding the medications and patient identification, etc.).

Above all else in a case like this it's best not to cover things up. People are smart and generally forgiving if no harm is done. But people get very pissed off if they're lied to. Mistakes happen and most people, if no harm is done, will grumble but eventually they'll get over it. But if the patient/family feels like something is covered up you can believe that the s*** will DEFINITELY hit the fan. Multiple studies (which I'm too tired to reference at this moment) back this up.

 

[automaton]

thanks guys. this didn't really happen but something similar did involving a switch from one person to another. i thought that just switching the names alone was unprofessional. one of my friends said that it's possible that this person in question would cover it up just because it's a huge screw up and someone that highly ranked in the hospital food chain would never admit to doing this. my initial reaction was like, how the hell would anyone with a conscience do that? but then i thought about it and it did seem like a possibility. anyway, i won't go into the real details of what exactly happened, but this error screwed someone pretty badly (not like taking out the wrong kidney or anything) and i just wanted to see what others felt about something like this.