Medication Error, comment

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Adhering to the 6 right of medication administration is really the only sure way of preventing medication errors the best way we can. As a nurse who works on very busy and fast-paced area, it is very easy to overlook the 6 rights, especially when you are pulling meds from a medication-dispensing machine. An incident similar to this one occurred on my unit not too long ago. Fortunately, it did not result in patient harm or death. Misoprostil is used on my unit for cervical ripening. The M.D. ordered for the nurse to place 25mcg of misoprostil. The tablets normally come in 100mcg or 200mcg form. As far as everyone knew, we never had 200mcg tablets. The nurse pulled a 200mcg tablet, and without looking at the label, cut the tablet into 4’s. The patient ended up getting twice the correct dose. The pharmacy had stocked the wrong amount even though the nurse thought she was getting 100mcg. So, it is very important to read labels on medication prior to giving them to the patient, even if you think you are getting the right thing.

Original Post:
September 24, 2007
In 2006, a Wisconsin nurse administered the incorrect medication to a 16-year old girl who was in labor. The medication killed the girl almost instantly. The nurse had been working in the field for 15 years and was described as very competent. Following this incident, it was determined that the medication was labeled incorrectly. The nurse was subsequently charged with involuntary manslaughter.

In reading about the 6 Rights of Drug Administration, I couldn’t help but think of this case and so many other cases with similar circumstances. Any system is going to have flaws as humans are the ones designing the system and entering the data into the system. The 6 Rights can be adhered to, which will greatly reduce these types of occurrences, but they won’t be eliminated.

The charges against the nurse were dropped, but it’s something that she will have to live with for the rest of her life…that’s more punishment than any court could have imposed on her.

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