The last line of defense

September 24, 2006 -- Today the Indianapolis Star ran a fairly good article about the tragic deaths of three NICU patients at a local hospital. Tammy Webber and Staci Hupp's "Infant deaths put focus on nurses" reports that three newborns died at Methodist Hospital after five different NICU nurses mistakenly gave patients adult doses of Heparin. That reportedly happened after a pharmacy technician mistakenly supplied the NICU medication cabinet with the far more concentrated adult vials. The piece discusses how the tragedy might have happened, inquiring into staffing levels, though not making much headway there. It explains the "five rights" system for avoiding such errors. And it quotes a local nurse who gives a balanced reaction to the events. It might have consulted a nursing policy expert along with the medical school and pharmacy professors it quotes on issues surrounding such errors. Still, we thank the reporters and the Star for their generally fair coverage, which underlines "nurses' critical role as the last line of defense in treating patients."

The piece explains that after two children received heparin overdoses in 2001, Methodist changed its practice so that only the children's dose of the anti-clotting drug was allowed in children's areas. However, in the weekend before the piece, five of the hospital's nurses apparently gave adult doses to six NICU infants. A pharmacy technician "with 25 years of experience" had reportedly delivered adult strength doses to the NICU medicine cabinet. The article notes that the medication vials were the same size, but the adult dose vials were dark blue rather than light blue, they said "Heparin" rather than "Hep-Lock," and the labels specified the different dosages. The piece says that "[w]hen the nurses discovered their mistake, they immediately gave the infants a drug to reverse the effects of heparin." Unfortunately, they were only able to save three of the infants. The phrasing of the account of their efforts is noteworthy because it tells readers, even in this unfortunate context, that the nurses were at least able to recognize their mistake and act to address it.

After these errors, the piece says, Methodist has begun to require that its pharmacy double-check all drugs leaving its stockrooms, and that two nurses "validate doses" to be given to infants. The hospital will also reportedly "try to speed" the institution of a new system in which scanners match bar codes on medications and patients' wristbands, to add an additional check that the medication is the correct one. However, the hospital apparently will not be be disciplining or firing its employees, despite reported calls for that from "the public and victims' families." The hospital reportedly has accepted the blame itself, "saying the errors showed a failure to have enough safeguards." Apparently a risk management committee will evaluate whether any of the nurses had any "pattern of mistakes."

The piece gets some useful comment from Methodist representatives. Spokesman Jon Mills notes that the hospital's ICU nurses typically have one or two patients, but that he does not know the NICU ratio at the time of the incidents. The piece does say the NICU had 27 patients at that time, "four more than normal." This is good context, since staffing levels are very relevant to how such errors can occur; the reporters were asking the right questions. Of course, that's just one of a number of potential factors, and the piece might have sought comment from the NICU nurses (or if none chose to speak, noted that fact). It might also have made more explicit why staffing levels matter, i.e., research shows that lower nurse staffing means more errors and worse patient outcomes. The piece quotes Richard Graffis, the "chief medical officer" at Methodist's parent, Clarian Health Systems. He says human errors are possible no matter how hard we try to prevent them, and that the organization "expects[s] no complacency" from staff because that's when errors can happen. That's fair enough, but we wish the reporters had sought some comment from nursing managers at the hospital or its parent.

The article also consults outside experts, who suggest that hospital environments can indeed lead to "complacency and miscommunication." University of Arizona pharmacy professor Lyle Bootman, "who specializes in medical errors," underlines the complexity in hospital medication administration. The piece says that Indiana hospitals must now publicly report their errors, but that some "researchers" say a real reduction of errors will require that individual nurses and physicians also be held responsible. It quotes University of Pennsylvania medical ethics professor Arthur Caplan, who would like to see the error reporting apply to individuals as well. Again, it might have been helpful to consult a comparable nursing expert, since nursing is the main subject of the article. Such an expert might have discussed the challenges nurses face today in clinical settings--which would of course affect individual error rates--and the effects of nursing errors generally.

The article reports that local nurses were "disturbed" that the Methodist nurses did not seem to have observed the "five rights," making sure they had "the right patient, right dose, right route, right time and right medication." Rebecca Teeple, a nurse at Adams Memorial Hospital, says:

Unfortunately, it does boil down to nurses who did not properly check the dosage on that vial...I guarantee you I was being even more careful than I normally am; I think it's made nurses very much more aware that it could happen to anybody. But I can definitely see in a very hurried environment how that could easily have been done...Some people just want to take the nurses out to Monument Circle and shoot them, but it's easy to sit in judgment if you have no idea what it's like.

Here again, we get a hint of the role short-staffing might have played. Teeple notes that she herself has made medication errors, though the piece notes that they "didn't lead to death." And the piece relies on "nurses and others" for its conclusion that even with "the best technology," "the bottom line is this: Nurses put the medication in a patient's body."

Of course, medication administration is just a small part of what nurses do. But the mass media commonly ignores it, trivializes it, or even suggests that physicians do it. So it's helpful to see some recognition of how important it is, even in a tragic context like this.

See the article "Infant deaths put focus on nurses: Experts: Despite safeguards, complacency is a danger" by Tammy Webber and Staci Hupp in the September 24, 2006 edition of the Indianapolis Star.

Authors Tammy Webber and Staci Hupp can be reached at: tammy.webber@indystar.com

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