Nurse commits suicide after making medical error.

[BHaus9]

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Nothing, you can have excellent skills and still be weak overall. For an analogy, look at Tiger Woods and his abilities, now see how he is golfing in the real world. I don't think anyone would call Tiger a bad golfer, but he has some serious issues with his game, it is currently a weak game compared to his peers. Understanding context is part of solving mathematical problems. Hence my comment on her most likely being weak in the math DEPARTMENT.

She made a life/death computation haphazardly and messed up. The dosage was over an adults dosage and she worked in the NICU. She should have known that. Would you prefer I call her incompetent or grossly negligent? That is how her error was probably categorized by both the state and her hospital, based on her sanctions. Would you prefer I say that to honor her memory? I don't fully agree with that, but that is how she probably was judged.

This is a math issue, no argument there right? You yourself have pointed this out. The reason it is a math issue, is that in the context of this problem she did not place enough priority on calculating the dosage correctly. Now the question is whether or not it was likely a pattern. From my exposure, and knowledge I would say that it likely was an issue. Obviously the hospital, and her state board thought so. What makes you think otherwise? Her perfect record? Really? The hospital did not report that, as they said they would not extrapolate, so you are operating on second-hand data. You are also being very naive if you think a perfect record means anything. It just means she did not ever do anything serious enough, to be reported. NO ONE is perfect.

Lastly, posting walls of text with exaggerated formatting to attempt to prove your comment, is not honoring her. You said my educated opinion as a fellow Nurse was asinine and baseless. What exactly are your qualifications to state that?

"Educated opinion" would suggest you're drawing on actual evidence, rather than broadly and blindly claiming that someone is mathematically inept. Sharing a profession with someone doesn't exactly make you telepathically linked. As you said yourself, NO ONE IS PERFECT. Michael Jordan missed shots occasionally, even when he knew they were REALLY, REALLY IMPORTANT. That in nowise suggests he was a below-average shooter. The fact is, this nurse DID know she'd overdosed, hence her immediately notifying other staffers. Is she unimpeachable? Hell no. But to blatantly ascribe the whole incident to a lack of concern and/or aptitude on her part is preposterous, and that's exactly what you've done. Your rambling, incoherent attempt to backtrack out of that stance is a fail.

 

[RNwantDO]

"Educated opinion" would suggest you're drawing on actual evidence, rather than broadly and blindly claiming that someone is mathematically inept. Sharing a profession with someone doesn't exactly make you telepathically linked. As you said yourself, NO ONE IS PERFECT. Michael Jordan missed shots occasionally, even when he knew they were REALLY, REALLY IMPORTANT. That in nowise suggests he was a below-average shooter. The fact is, this nurse DID know she'd overdosed, hence her immediately notifying other staffers. Is she unimpeachable? Hell no. But to blatantly ascribe the whole incident to a lack of concern and/or aptitude on her part is preposterous, and that's exactly what you've done. Your rambling, incoherent attempt to backtrack out of that stance is a fail.

Educated opinion, means I know the standard of practice. I never said she was mathematically inept. I said she was most likely weak in the math department. I will not argue with you on a stance that is not mine. Comparing a basketball shot to a math problem is non sequitur.

 

[eli20]

Based on user name I'm thinking there's a little bit of self-hatred going on.

 

[ucladoc2b]

I am a Pharmacy intern. I've made medication errors, I will be flat out honest. I've grabbed a Lopressor instead of a Toprol. I've grabbed hydralazine instead of hydroxyzine because someone stocked them wrong. Who's to blame? ME.

You're forgetting that the pharmacist has the final check. The pharmacist's job is to make sure the medication is appropriate and dispensed properly. That is the 2nd chain that shouldn't be broken.

Here is your full chain:

MD -> CPOE -> Pharmacist (who has to verify before the order even is available for the tech to fill) -> tech (who brings medication) -> Pharmacist for check -> i don't know how CNA's fit in, but I would assume nurses are the only ones that administer.




The only weak link in that chain is CPOE, technician... so far. If the pharmacist can't be half assed to do his/her job and look up the dose then if the patient dies due to a med error there should be no whining or complaining from their end. As harsh as the other punishments.

In your situation the pharmacist grabbed the wrong bottle. I wonder what the consensus here would be if that happened? Headline: pharmacist accidentally kills patient after selecting wrong bottle. No sympathy, that's what would be the consensus.

This nurse simply made a decimal error as stated. That's the final weak link.We don't fire people for their mistakes if it doesn't kill the patient. Once the patient dies it's a whole different story. All it takes is an insulin bolus to kill someone and we're in a whole different situation than an underdose of insulin.

You're comparing the weather to an ill person. In both cases, there is variability - no one can control the weather or accurately predict nature's path. Medicine is supposed to be more refined because each step is controlled (in a major part) by humans. There is no check and balance for the path of a hurricane. There are multiple hurdles for medicine.


MD prescribes methotrexate 20mg TIW for rheumatoid arthritis.
Pharmacy technician types 20 mg TID because he can't make out the handwriting.
Pharmacist approves it because he misreads the diagnosis.
Patient takes it exactly as directed and dies.

Who is to blame here?
MD, for prescribing wrong dose for pathogenic condition.
Technician, partially, for not asking for clarification from MD.
Pharmacist, definitely, for approving it if it wasn't clarified.

I deal with this every day. MD's asking for Advair 2 puffs BID, turns out they wanted the HFA. A pharmacist who approves it is as guilty as the MD that wrote it.

There is a system of checks and balances that are supposed to eliminate

medication errors. If a check and balance doesn't work, accountability needs to be held. The severity is based on the medication, negligence, and patient status.

In the end, I'm just really sad this nurse killed herself.

Why are you so focused on retribution for mistakes instead of correction? If you ever get a chance to review error reports and follow the workflow, you will see the same errors over and over again. Would punishment really help? Or will it just propagate the errors even more by keeping them suppressed?

Honestly, grabbing the wrong drug stocked where the right one should be would be only partially your fault.

Check and balance systems work well. Until they don't.

 

[NightGod]

Educated opinion, means I know the standard of practice. I never said she was mathematically inept. I said she was most likely weak in the math department. I will not argue with you on a stance that is not mine. Comparing a basketball shot to a math problem is non sequitur.

Any more non sequitur than comparing drug over dosing to a golf shot? If you're going to play one type of game, don't get mad and take your ball home when someone else joins in.

 

[RNwantDO]

Based on user name I'm thinking there's a little bit of self-hatred going on.

Not self-hatred but fear. I fear to God that I may make a mistake like this. I am a new Nurse, and plan to ALWAYS follow protocol. Will I, probably not, because it is impossible to be perfect. I am truly sorry that she did not seek out the help she needed, and no one was able to intervene. There was no need for her to kill herself, and I think the punishments received, seem severe compared to the story.

On that, the reality is that it is extremely difficult to follow protocol, and there is a ton of pressure to bend the rules. It is part of the culture in the nursing world. I was attempting to give fellow pre-meds a glimpse into the nursing world. You know make a tragedy a learning experience. Especially since most pre-meds will not be exposed to the nursing world until MS3. However, with the reception I have received I doubt I will do this again. As there appears to be plenty of specialists in the nursing field on this part of the forum already.

Any more non sequitur than comparing drug over dosing to a golf shot? If you're going to play one type of game, don't get mad and take your ball home when someone else joins in.

Really? I was comparing her math abilities to someone's golf abilities. They both are a learned skill over time, and you can be ranked compared to your contemporaries. This was to illustrate how one can be overall weak, and yet still be strong at a single component.

Versus: A math problem which is pure logic, you can double check it and verify that you did it properly. A basketball shot cannot be double checked, and outside variables can effect outcome.

 

[BHaus9]

Educated opinion, means I know the standard of practice. I never said she was mathematically inept. I said she was most likely weak in the math department. I will not argue with you on a stance that is not mine. Comparing a basketball shot to a math problem is non sequitur.

How are these so different?

 

[BHaus9]

Not self-hatred but fear. I fear to God that I may make a mistake like this. I am a new Nurse, and plan to ALWAYS follow protocol. Will I, probably not, because it is impossible to be perfect. I am truly sorry that she did not seek out the help she needed, and no one was able to intervene. There was no need for her to kill herself, and I think the punishments received, seem severe compared to the story.

On that, the reality is that it is extremely difficult to follow protocol, and there is a ton of pressure to bend the rules. It is part of the culture in the nursing world. I was attempting to give fellow pre-meds a glimpse into the nursing world. You know make a tragedy a learning experience. Especially since most pre-meds will not be exposed to the nursing world until MS3. However, with the reception I have received I doubt I will do this again. As there appears to be plenty of specialists in the nursing field on this part of the forum already.

From what I've read, you just more or less bashed this nurse and provided no edifying insights into the matter whatsoever. Don't drive the turnpike of righteousness when you clearly haven't paid the toll.

Mightn't a little bit of a superiority complex have something to do with your proposed career change? Cuz you're certainly coming off haughty.

 

[RNwantDO]

How are these so different?

Inept implies that she was incompetent at math. That is an extreme stretch of logic, and I would expect to be called out on saying that.

Being weak in the math department is saying she has a weakness within her skills. She probably was weak at application. We are taught to always double check our calculations, and never do them in our head. In addition a High-alert med is a situation where you should have another nurse verify both the medication and your calculations. She apparently did not do these things (sanctions and being fired). Therefore she was most likely weak in the math department. She did not apply her knowledge to the situation at hand, and realize she was at high risk for making a computational error that could kill someone.

 

[RNwantDO]

From what I've read, you just more or less bashed this nurse and provided no edifying insights into the matter whatsoever. Don't drive the turnpike of righteousness when you clearly haven't paid the toll.

Mightn't a little bit of a superiority complex have something to do with your proposed career change? Cuz you're certainly coming off haughty.

Yes my initial post was weak. However, I did clarify and expand once called out on what I said. In addition my posts have been butchered as far as what I said, and what was interpreted. I say almost, it gets taken as absolutely. I say most likely, it gets taken again as an absolute.

Nope, I just love science, and math. Nursing is more art than science. Also, I would say I am no more haughty than the people attempting to call me out.

 

[BHaus9]

Yes my initial post was weak. However, I did clarify and expand once called out on what I said. In addition my posts have been butchered as far as what I said, and what was interpreted. I say almost, it gets taken as absolutely. I say most likely, it gets taken again as an absolute.

Nope, I just love science, and math. Nursing is more art than science. Also, I would say I am no more haughty than the people attempting to call me out.

The problem was that it's still difficult to see where the "probably" and "most likely" come from. Speculation is speculation.

And you're right. I shouldn't have questioned your reasons for changing. Nor was it my original intent to attack you per se. Also know that I'm by no means trying to exonerate this nurse's mistake or the subsequent taking of her life. It's just that I think it unfair to attribute flaws to her for which there was no evidence in the article, especially seeing as how she's not here to defend herself. The rather extreme decision to terminate her immediately DOES raise suspicions, but why is it more likely that she had a boatload of unspecified offenses than that the hospital administration overreacted? At any rate, sorry, and best of luck in your transition.

 

[The right Path]

Oh really? Are you a nurse? Do you know the procedures and protocols for administering medications? You do realize this is a high-alert medication, for this very reason don't you? She violated accepted practice for this life/death medication, specifically with regards to it's computation of dosage and administration. That is not an implication, it is a fact. Now explain why it would be asinine and baseless to think she might have an issue?

Look I respect that she was probably an excellent nurse. She worked in the NICU which is a very difficult and stressful department, for this very reason. I have no doubt that she was probably adequate in her mathematical skills. This was a simple computation. She probably became complacent in administering high-alert medications because she did it daily. However, that is a math issue, and a serious one as someone's baby may have died directly from this "stupid" human error.

I'll throw a couple more chips in since I am a nurse, fairly well seasoned (7 years), and I am active in my hospital's medication safety activities. Hopefully, this is enough to validate my viewpoint.

I don't agree that in general this nurse's math skills were weak. If that were the case, she'd have a trail of dead babies over her extensive career (25 years, no?). Rather it sounds that you're projecting your opinion that in general, nurses are weak in math. So if one makes a mathematical error, one must be weak in math. Perhaps in your particular nursing program (in your experience) your classmates were rather sucky in the math department. You can't apply the low standards and performance of your own school to the rest of the nursing world.

I am personally quite strong in math. Easily aced calc. I got a 750 on that part of the GRE (I didn't finish all the questions, cuz I'll admit I'm not very speedy when it comes to math). Despite the fact that I can handle complicated math, I would still consider myself vulnerable to computation errors.

Let me make this analogy: Here I am fixing up dinner, but I am adjusting the quantities of the ingredients to accommodate several dinner guests. I am under quite a bit of pressure because I'm trying to hurry and get the meal prepared on time while at the same time my children are bickering, making messes, etc. Under these circumstances I could easily screw up my computations- and I have (been there and done that). However, there is no double check process, no computer to compare my calculations to. Thank god no one ever died from horribly dry banana bread.

If I recall correctly in the NICU, but I'm sure every hospital is different- all medication dosages are independently calculated by two RNs. Perhaps this is the safety mechanism that the nurse in the story skipped. This safety mechanism is to catch computation errors made by nurses who are brilliant in math but are harried and distracted.

 

[pfaction]

How are these so different?

I can speak English, but I'm not a scholar.

I can do the basic of basic of algebra, but I can't do pre-calc well.