You don't need to be an 'investor' to invest in Singletrack: 6 days left: 95% of target - Find out more
Mrs Zip's mum has been having a series of falls. After a few trips to hospital she was prescribed vitamin B12.
The nurse turns up at her home ,gives her the jab and the next day she goes from being able to live independently to being barely able to stand.
A few days later a different nurse turns up to give another jab.She looked a bit flustered and said this is the wrong drug. Instead of B12 Mrs Zip's mum had been given Haloperidol.
https://en.wikipedia.org/wiki/Haloperidol
The pharmacy had put the B12 label on the haloperidol box and the nurse had then administered the wrong drug ,even though it clearly says what it is on the box.
We had to look after 24 hours a day. Eventually having to to put her in a care home for 3 weeks til she was able to fend for herself at a cost of £5000.
We asked the doctor to investigate what had gone on and apparently it was just 2 cases of human error and there is no case to answer for.
Everyone we have spoken to who gives injections has said that checking that WHAT is given to WHOM is the first thing you learn.
Is this just a case of human error or can we pursue this in some way?
Jesus wept that's terrible.
I'd say you can definitely purse this. But I'd have wanted my mum admitted to hospital rather than a nursing home at the families expense.
That's awful.
Is this just a case of human error or can we pursue this in some way?
I don't see how these are mutually exclusive. If you kill someone in your car because you weren't paying attention, that's human error.
I don't know what the process is but there surely must be one. Good luck.
Is this just a case of human error or can we pursue this in some way?
Absolutely - contact a specialist medical negligence solicitor...
This is awful. I think medical negligence solicitor. Im really hoping she is well now. This could have turned into a fatality
Ian
Human factors definitely play a part but a routine meds check prior to adminstration should reduce the likelihood of this.
Sounds like multiple failings from the pharmacy incorrectly labeling the medication to the person administering it not reading the drug ampoule once out of the box.
Patient Advisory Liasion Service of the local Clinical Commissioning Group would be the way to address the error.
The human factors element of the mistake would be for the employer to investigate and recommend an appropriate outcome; hopefully a genuine mistake wouldn't see anyone sacked, however that has no bearing on you contacting a solicitor as others have said and pursuing that avenue for recompense for the suffering and financial burden the error has caused.
Good luck and I hope you get an acceptable outcome.
Err yes that’s a medication error, that has caused harm. How far you take it is up to you and depends on what you are looking for- apology- formal complaints process- if not satisfied then up to parliamentary ombudsman… if compensation then lawyer up.
Read the OP’s post out to my wife, as soon as i told her the name of the medication she burst out “bloody hell!”
Medical negligence springs to mind IANAN.
If everything as is you say it is that that is professional negligence on part of both the pharmacist and nurse, mistake but still really serious. Both will have a statutory responsibility to report it to be investigated. You need to raise formal complaint with your NHS Trust both for your mums sake and also for the safety of other patients. It might be a one off or one/both of them might be making regular errors, these will only be resolved if people report it.
Is that not a cqc reporting issue? Or is that care homes only?
Definitely a medicines error and should be investigated, answering human error to that is utterly shameful as a mistake like that could easily kill someone
also, did anyone else read this post and think of this....
Just about to have to go through a medical negligence case myself, which saw the Doc dismissing a cancerous tumour in my colon as nothing...
A friend who used to work in this industry has said to speak with Irwin Mitchell...
She's they more than likely won't take it on if they don't think it's cast iron you'll win, so at least you'll know pretty quickly, but that they have a fearsome reputation in this industry...
Sorry to hear your story but that's an absolute shitshow that should never have happened!
****inell that's terrible. Report it to you local health authority and although I'm generally against involving lawyers where possible I'd definitely be speaking to one in this case.
This sort of error should not happen especially as there were two of them here. Absolutely no excuse for it if either the pharmacist or first nurse were doing their job properly.
We asked the doctor to investigate what had gone on and apparently it was just 2 cases of human error and there is no case to answer for.
Total BS.
Sadly, until you lawyer up the system isn't interested in learning from it's mistakes....
Not a lawyer but do work in healthcare, this should be reported as a incident (our system is called datix) and most likely should be declared a serious incident (SI) and be investigated with the report presented to you and your family. When it gets investigated you will likely find there are 4 or 5 things that have gone wrong/contributed.
For example: In the pharmacy the wrong label was put on but normally there would be a second check but someone was off sick so that step was missed. The option is don't get the treatment out because there isn't a second check and deprive people of medication or live with the skipped step. Nurse should have had 8 patients to visit but actually was seeing 12 so was rushing round and didn't follow the usual process, again a mistake but can she say no to the extra 4 patients etc etc.
This doesn't excuse what's happened at all but is a sign of the times in the health service now.
Within my team we have seen several near misses over the last year which have been picked up but have kept me awake at night as the consequences could have been catastrophic.
Without being political these incidents have happened more in the last year than the previous 20 due to staff being overstretched/high sickness/vacancies and is the main driver behind the industrial action from the nurses.
Top tip: don't bother with the Parliamentary and Health Service Ombudsman as their remit is to defend the state regardless of harm or atrocity that has been caused. Bear in mind that the NHS has an unlimited pot of public money to defend itself and relies on the public being unable to afford to take legal advice and action. Have you considered reporting this crime to the Police? Get the local MP involved?
Bear in mind that the NHS has an unlimited pot of public money to defend itself
I don't think that is accurate....every trust pays an "insurance premium" to a central body to cover medical negligence claims...that premium has to come from somewhere
Have you considered reporting this crime to the Police?
Can you be specific about the crime here? I'm not seeing any intention to cause harm at face value
So sorry your MIL and your family has had to go through this, it sounds horrible.
I read the OP out to mrsmidlife, who winced and thought it likely to be clinical negligence. She isn’t a nurse but is a director of one of the country’s biggest medical negligence solicitors firms. Not irwinmitchell, though they are fine too. I’ll not link the firm here as not touting for business, but happy to pass it on via PM.
Mr midlife ,that would be useful.
Wow - good to hear she's improving
It's an easy mistake to make in one sense (hydroxocobalamin is presumably very close to haloperidol on their shelf)
... and that's why the system is supposed to incorporate a lot of checking, starting with the pharmacy, where a second check is pretty much built into ALL working practice. There will have been a "responsible pharmacist" on the day whose role is to ensure that safe practices are in place.
Of course errors do happen; it's just rare for one to get right through the system.
A really experienced nurse might've noticed that the injection solution wasn't the right colour but that's just the last little chance for not dropping the ball; checking the label & box should have been the point where the nurse pulled the pharmay out of the shit.
I can't imagine that this is defensible, particularly if the home can state how her recovery progressed over the "admission period". May well involve 2 different organisations (pharmacy and whoever sent the nurse) but that surely doesn't make it impossible to pursue - both should have insurance for exactly this sort of eventuality.
If I were you I'd be asking was it a depot formulation or not and what dose did she receive (intramuscular presumably)? Did anyone (medical) examine her before she went into the home and say what they thought was wrong?
After that it presumably comes down to what you want - just cost of the admission? Lost earnings for looking after her? More?
contact a specialist medical negligence solicitor…
Absolutely, and this whole "No case to answer' is a load of bollocks.
It's not a case of gaining compensation, which is totally deserved anyway given what the old dear has been put through, but also a case of it cannot be swept under the carpet and simply forgotten about. By involving a legal representative, more will be recorded and theres more chance lessons will be learned.
I’ll not link the firm here as not touting for business, but happy to pass it on via PM.
The forum T&Cs say something like, it's fine for legitimate businesses to respond to genuine queries, so you should be fine to do so if you wanted. And it might be useful to other readers.
apparently it was just 2 cases of human error and there is no case to answer for.
Nice try, but OP is at least 5 grand out of pocket, his mum suffered quantifiable harm, and it is as clear a case of actionable medical negligence as you can get.
The doctor who fobbed you off with this cobblers rather than start the process of reporting it as a serious incident is the reason why the NHS so often ends up getting expensively sued by people who aren't even necessarily after compo, but just want lessons learned and procedures tightened so the mistake can't be repeated.
I'd be more pissed at that doctor tbh....
I've done a few drug errors in my time. One of them was me injecting the wrong patient with a large dose of insulin. The reason why I did so was complacency.
The vial in the box labelled b12 should have been called "haldol" or haloperidol. The person giving it was either not fit to practice because they can't read a label or so complacent that they didn't read the vial.
I'd be pursuing it. Haloperidol is a dirty drug.
I was lucky. I was young in my career and the family of the patient involved laughed it off. I got a formal warning.
The doctor who fobbed you off with this cobblers rather than start the process of reporting it as a serious incident is the reason why the NHS so often ends up getting expensively sued by people who aren’t even necessarily after compo, but just want lessons learned and procedures tightened so the mistake can’t be repeated.
Exactly this. A friend is currently going through a horrible medical negligence case after his wife was injected with a significant overdose of whichever drug is used to bring on labour, which killed both her and their unborn daughter. The entirety of the hospital/doctor response was "human error, these things happen, sorry". Absolutely unforgivable the way he's been treated. Yes, people make mistakes and I can't imagine the guilt the administering nurse must be going through, but it's the tragic result of a catalogue of failures and just claiming "oopsie" is never going to solve anything.
Pharmacist here. Firstly, sorry to hear this has happened and hope your mother in law is on the road to recovery from what she has experienced. It does appear to be a fairly clear case of negligence causing harm. Also agree that if this was assessed and given a risk score in a system like DATIX it should be high enough to warrant thorough investigation. My main issue here is the brushing off of it by the doctor.
As for the error itself, I have actually seen an almost carbon copy of this error happen before. I was working in medicines information at a community trust and got asked for advice about potential adverse effects from a patient being given a dose of hydrocortisone intramuscularly instead of hydroxocobalamin (B12). In this case the patient suffered no harm but it was fully investigated and I expect there will be many parallels with your incident.
As alluded to by scardypants, the medicines would most likely be located next to each other on the dispensary shelf and it would be a picking error by a dispenser. The pharmacist should of course have picked the labelling error up when it was second checked, which I am almost certain it will have been, although obviously not to the right standard in this case.
Checking dispensed medication is a horrible combination of being a high volume repetitive task that is being done in a highly pressured environment with lots of interruptions and distractions, but where you need to be very focussed and accurate. I have made checking errors in the past and when they come back and you look at them in the cold light of day, you wonder how you missed it, but then you think back to the environment and what was going on at the time and then you realise how these things occur. My first question would always be ‘is the patient ok’…and then you pray. I’ve been lucky but that’s all it is. I think published error rates for dispensary accuracy checking are about 1% but with the pressures on the health service, which are as severe in pharmacy as anywhere else, you might expect that to creep up.
It will most likely be the same story with the nurse. You will probably be aware in the news of all the pressures in the ambulance service and hospitals with bed blocking, so there will be a huge push to get patients out into the community to be managed by district nurses. I don’t know for sure, as not worked in that sector for a few years, but I would be fairly confident that the numbers of visits DNs are expected to do in a day will be going up and up and again you might expect to see error rates rise.
There is something called the Swiss cheese error theory. Each check in a process is a defence against an error occurring but they are not perfect and are likened to a slice of Swiss cheese with holes in. If an error is made in one check and it gets through a hole in the Swiss cheese, then it usually gets stopped by the next one. Errors like this occur when all the holes line up. As pressures grow, sadly there are more holes and they’re getting bigger.
Of course none of what I have described above is to excuse what has happened but just to give some context as to what might have been factors. It does need to be investigated to identify any systems issues that can be addressed at a minimum. As you have have suffered quantifiable financial loss as a result of the error then you have every right to pursue that so you can be compensated. How hard I would pursue I think would depend on the responses from the organisations and individuals involved. I would expect the pharmacist and nurse to be mortified, as I would be. I would be concerned if there was any attempt to brush it off rather than to express sincere regret and to apologise and look to what lessons could be learned.
Sorry again to hear of this and hope you get to a resolution and that your mother in law is ok.
I work in health care and I fully agree with alansd1980, it needs to be raised as a DATIX and a root cause analysis completed. In my work this would likely be classed as a serious incident and investigated accordingly, i.e the more serious the incident the more senior the investigators.
Investigations are not about wriggling out of fault, they are about trying to find out what went wrong and how can it prevented from happening again.
I'd suggest the local PALS service if it was a hospital staff member. If you get no joy then you can make a formal complaint to NHS England who will take it forward on your behalf with all parties concerned.
You will get a formal written response answering your complaint and when you submit a formal complaint they will also give you date by which you will receive the report of the investigation.
Had to do too many of these recently.
Ignoring the terrible error for a moment, I'm really surprised YOU were left responsible for caring for the patient...
If as a GP this happened to one of my patients, regardless of the GPs lack of initial involvement, I'd be admitting the old girl to hospital! Needs monitoring, care, and potentially life saving interventions...
Haloperidol can knock you RIGHT OUT!
Have you considered reporting this crime to the Police? Get the local MP involved?
Again, not really a crime for the police to be involved in though.. a mistake that needs looking into, but not a crime...
DrP
Dr P ,once the GP realised they were in the clear we didn't hear another thing from them.
I'm another pharmacist, and right with Blitz. First off, I'm glad to hear your MiL is recovering.
The pharmacist will almost certainly be absolutely gutted and has a professional responsibility to follow through with an investigation... and will most likely be very keen to do so - we hate making errors, even tiny ones, but it is inevitable as no process is perfect.
Having said that, what we have here is known as a SALAD error - Sound Alike, Look Alike, Drug - sound alike in this case.
I've been a community pharmacist for coming up on 30 years; when I started there were faded old stickers on the shelves trying to point out and prevent this sort of error so it's been a problem forever, basically. As I'm certain that literally thousands of highly qualified and highly motivated pharmacists have been trying hard to reduce and ultimately prevent this sort of error without great success for at least those 30 years, it has become clear to me that this is not a problem that can be sorted completely within the dispensary. The EU's Falsified Medicines Directive might have helped as it required a scanned match between the product and the prescription, but only about a third of manufacturers were on-board, it was very time consuming to implement, and was dropped in the UK following Brexit anyway. Although when I say "required", it was possible to skip past the warnings anyway ( Alert fatigue ), so although it was another slice of swiss cheese, with small holes, holes are still there (the extra time it took of course made missing the alerts more likely as you're having to do more with each script in the same time).
I've rattled on probably more than I intended to, but hopefully it's helped you see that we do (most of us) take errors very very seriously.
I believe Blitz is mistaken on the error rate leaving pharmacy - the research I was studying a few years back gave a rate of 1 in 10,000. In fact I knew a pharmacist who was making a job out of presenting to other industries how pharmacy gets the error rate so low. But a busy pharmacy will be doing over 10,000 items per month, so are likely to have at least one error per month... luckily, most are far less serious than the one here.
It's essential that you do approach the pharmacy. If you don't tell them, they're just that bit more likely to make the same mistake again! But hopefully I've explained enough that you won't feel it necessary to go in shouting (we completely understand why you might, but it doesn't help us deal with it well straight off... again, we are human!) - a calm approach explaining what you believe has happened and the consequences, with a request for their insurer's details and a further request to be kept up-to-date with the results of their investigation should give you what you need. If you could take the original box with the label on it, it would help them a lot as it should have the initials of the dispenser and checker on it, which helps us see who did what. If you want to keep it as evidence, then the pharmacy will probably want to take a photo. Don't panic if they ask to keep the box themselves though - this is normal and we keep it with the details of the investigation. However, with the district nurse involved as well here, it may not be appropriate.
Finally, on the results of that investigation... as the dispensing happened some weeks ago, it's unlikely that anyone involved will remember it especially. It may be they find stock is muddled on the shelf; that they were very short staffed or massively busy that day (although a very quiet day can lead to more mistakes as you switch off a bit!!); or something similar... but at the end of the day, this is a SALAD error and it's known to be both the most common and hardest to catch (cause/effect issues there). Please don't feel that if it comes back as having no particular identifiable reason for occuring (beyond SALAD) that it's a cover up or whitewash; we really do wish we could say why we sent out nine thousand, nine hundred and ninety nine correct items that month ... and one wrong one.
You will probably be aware in the news of all the pressures in the ambulance service and hospitals with bed blocking, so there will be a huge push to get patients out into the community to be managed by district nurses.
That really is a horrible term, coined i would think be either the mail or the express. The fact there is the Conservative party closed down facilities where patients could be treated outwith hospital, and ceased funding the the district nurses and carers out in the community that took care of patients after they left hospital.
In 1998 I was in isolation in an infectious diseases ward, and I was pretty out of it. I knew I was on antibiotics and saline via a drip.
A nurse came in and injected something into the IV line, and said "I'll be back in a few minutes to give you your antibiotics."
I was very ropy, but managed to reply "I thought I was only on antibiotics?"
The nurse went to the door of the room, opened it, looked at the number and said "Oh! Sorry! Wrong room!" The line was stripped out quick enough that whatever it was didn't get as far as me, but I have no idea what it was.
This error meets the threshold of moderate harm and therefore the pharmacy has a legal duty of candour. https://www.gov.uk/government/publications/nhs-screening-programmes-duty-of-candour/duty-of-candour
They need to investigate how this happened and then meet with you. I’m surprised they haven’t. Pretty poor.
Sorry defblade - how exactly does vitamin b12 sound like haloperidol??? Not to mention that they are very much not even vaguely similar drugs either in type or alphabetically, so one would really hope not just sat next to each other in a pharmacy. Also as far as I’m aware Vit B12 injections are usually stored in a fridge, although it does depend on the specific type / brand. A quick check on Haloperidol reveals it to be fine stored at room temperature, not to mention in single use vials. Quite apart from the fact that a super long acting injection with major side effects deserves to be stored somewhere away from other drugs, these two drugs would not be next to each other and do not sound / look at all similar either spoken or on a label.
how exactly does vitamin b12 sound like haloperidol??? Not to mention that they are very much not even vaguely similar drugs either in type or alphabetically
haloperidol / hydroxocobalamin (B12) - I'd say proximity more than true SALAD but still a valid comment
B12 is very commonly a non-fridge item. I'm not aware of a product with ONLY this as active ingredient that needs refrigeration (particularly the 1mg/mL formulations anyway)
@andylc It'll be haloperidol/hydroxocobalamin, so they do end up near each other. Most pharmacies don't segrate further than by dose type (tabs/caps, injections, creams, sachets, and so on) and then alphabetically - space is usually at a premium for a start, and then if you split off clinical uses you run into all sorts of problems as many drugs have more than one indication. Packaging of all sorts of drugs can be surprising similar, too, especially if it came from the same manufacturer.
The length of time that the lady was affected for strongly suggests that it was the depot version of haloperidol, however, which likely makes a lot of the above less relevant as it would probably be a single vial in a cube-ish box, rather than a pack of 5 in a fairly flat box.
I'd be interested to see the label as well, and how it's been attached to the box. New, or poorly trained, dispensers sometimes put the label across the very information you need to read, such as name/strength/quantity/expiry date. Some packaging has a lovely space for the label to go, but no other information on that face, which makes checking the label against everything else that bit more difficult.
That it appears the nurse administering the injection also failed to pick up the error also makes me wonder about the packaging/presentation overall, and other details... the hydroxocobalamin would be watery, and a haloperidol depot oily... that perhaps should have been the final line of defense as the nurse drew up the injection.
I'm not trying to make excuses, we all make mistakes and I and most other pharmacists really do try to understand how and why. Sometimes you know immediately what went wrong (and the words "...and then I assumed that..." often appear in there if you're being honest with yourself), but sometimes you rack your brain for hours or days and just cannot reach an understanding.
There could be many factors which would move this from the realms of a simple error into possible negligence - if it turns out from the label that a final check wasn't done, for example; or a recorded history of regular major errors for that particular pharmacist/checker or pharmacy. Maybe they'll have CCTV in the dispensary, and the checker was busy playing on their phone while "checking". But it is far more likely to be an error that just slipped through the holes for no obvious reason. Either way, the insurance is extremely likely to be paying out on this one - albeit in split liability with the nurse's.
For more info, the single largest root cause of dispensing errors is poor lighting levels in the dispensary - something employee pharmacists have pretty much zero control over. This is one factor that makes SALAD errors that bit more likely to occur.
Whatever the ins and outs of this example, hopefully I've given an idea of how what looks like an impossibly negligent error can/does have many factors playing into it; and that this sort of error isn't only not impossible, it is inevitable that they happen from time to time.
I'm not impressed with the GP's reported response, but it does appear they are not at fault here. Hopefully, the response from the pharmacy and nursing team will be much better.
I said previously it would be good to go in in a calm fashion to discuss this (and, to be fair, I extend this to all problems with companies and services in my own behaviour. I've never quite understood what people expect to achieve shouting and swearing at staff; I find it locks my brain up defensively and makes it far more difficult for me to find a solution).
I'd perhaps go a bit further and ring ahead to arrange a meeting, possibly ringing the head office if it's a multiple. If it was me who'd made this error, I'd certainly appreciate the ability to address it out of hours, or arrange cover during the day, so that I could give it the full attention it deserves (while also not having loads of other work piling up while I dealt with it, making another error that bit more likely while trying to catch up...)
I’d say proximity more than true SALAD
Yes, I think I'm sort of coming around that, especially if it was a depot - 2 boxes of 5 amps of the non-depots would be easier to mix up, and a lot more understandable as a SALAD.
Here is the box. Front and rear.
Jesus that’s terrible for your Mum.
Pictures are pretty worrying. Not a pharmacist. I presume the ‘disp’ and ‘chk’ boxes are supposed to be different signatures?
Bloody hell, that's plain as day the wrong label, even just below the sticker it says haloperidol. I'm a nurse of 23 years, I simply cannot understand how that mistake could be made, and the ampoule would have haloperidol written on it.
That nurse needs NMC referral too, they're dangerous.
Hmmm.
It is the non-depot/immediate release version, which is easier to mix up in SALAD fashion.
But only one box signed, which immediately puts the pharmacist on a sticky wicket as, yes, there should be 2 initials there. 2 main explanations for that - either the person dispensing isn't following the Standard Operating Procedures and the checker (may not have been be a pharmacist) isn't pulling them up on it (which doesn't suggest a good safety culture in the dispensary); or the pharmacist has self-checked their own work and not followed the SOPs/best practice there.
It's hard to understand just how your own brain can fool you and make you see what you expect to see, not what is actually there... so if you do have to self-check, it's best practise to take a "mental break" between picking/ labelling and then checking your own work... and not to do that at all, if possible. I will ask any other member of staff to look over my work (as well as double-checking myself) if an accredited checker isn't available - it's still better than doing it yourself. So the signature in just one box suggests that, if it was all done by the same person, they failed to separate the 2 parts of the procedure, otherwise there would be the same squiggle in each box.
(Depending on the staff mix, there is also a chance that the pharmacist wasn't involved beyond a clinical check - and that would have been that the B12 was suitable, nothing to do with the haloperidol - but then the separation of dispensing and checking is required to be between 2 people, and the procedures and signing trail should be even more robust.)
I'm surprised anyone coming to it fresh didn't pick that error up however (either checker or nurse). It's neatly and clearly labelled, and for once the manufacturer's design puts the relevant info right where you need it.
@zippykona this is looking less like one of the inevitable human errors I've been talking about, and more like a failure to follow procedures, which casts a different light on it. While I can picture the way/s the error may have happened in the dispensary, I'm surprised still that the nurse didn't pick it up - I know far less about their procedures, but can't imagine that the checks aren't there. But going back to the Swiss Cheese model, sometimes all the holes line up. Looks like the pharmacy has reduced the number of slices (less people involved in the process, so less chances to catch the error) and/or made the holes bigger (not following SOPs) - both of which makes a mistake more likely, and harder to defend when it happens.
I'd still advocate ringing ahead to arrange a chat. And I still think that a calm approach is best! But you should now be able to make it clear that, while you're sure they didn't do this on purpose, you have realistic concerns as to how/why it was able to leave the dispensary. Please remember also that you may not be talking to the person who dispensed the item - they will be able to tell who was on duty the relevant day - it may have been a locum pharmacist (self-employed, they cover holidays etc around many pharmacies) who did the whole thing themselves and not actually how the dispensary normally runs. In any case, you will be asking for their insurance details.
They have a duty of candor; you should expect their response to include where they have reported the incident on to (the Health Board via DATIX in Wales, not sure about England these days)... and a simple apology should be in there somewhere.
If you are not happy with how they are responding, then your next step is with either or both of the local health authority (who you may well be talking to anyway regarding the nurse side of matters) and the General Pharmaceutical Council.
I hope this is all some help.
It sounds like negligence to me. Speak to a solicitor who specialises in this, if you have a case they will take it on, sadly it happens far too often in the NHS.
That's no offence to the thousands of good people, but my dad sued and got a 50k settlement, due to miss-teatment of his late wife.
Unfortunalty in this particular instance, aside from from the pay out, the very highly paid 'consultant' at fault in question, simply got moved sideways rather than struck off.
I have nothing to add beyond noting that, yet again, when you really need an expert someone on STW will step up and provide real help.
Kudos @defblade.
As someone who delivers therapeutic injections I always check the box it is in and the individual vials. Before delivering the injection the batch number, expiry date and dosage administered at written in my notes. I do this before the injection to make sure what I'm going to inject it in date and correct.
I work on the premise you can't be too careful .......
Not the first to say this but there is a clear system there (we use the same in a vet practice) where the dispenser marks and then someone double checks - this has not been followed.
Also I’m somewhat surprised to see a tick not an initial. If you’re looking to have a chain you can follow when something goes wrong then these should surely be initially not just ticked?
This goes back to my original point in the its never a single mistake which causes a SI/Datix.
Wrong label put on bottle
Second check process has broken down
Nurse who injected didnt check that the bottle matched the label etc
When the investigation happens I would be willing to bet there are staffing issues what have caused the second check not to have occurred and not simply due to someone not caring plus the nurse was doing more than they should.
To the pharmacists here, if there is no one to do that second check should the treatment not be dispensed or is it ok for it to be given?
Just noticed that my local pharmacy as well.
In my work this would likely be classed as a serious incident and investigated accordingly, i.e the more serious the incident the more senior the investigators.
This error meets the threshold of moderate harm and therefore the pharmacy has a legal duty of candour.
Something is fundamentally wrong if that gets applied here.
A double (at least) system of checks failed.
The severity of that particular set of failures is immaterial to the system.
Basically "Oops, we accidentally picked the one on the left of the correct item not the one on the right/aove/under...???"
Sounds horrendous, must be challenged. Matthew Syed's Black Box Thinking covers some of this, he argues there seems to be a complacency or hubris in (some parts) of the medical community that means that these types of issues are just shrugged off as 'these things happen' rather than a desire to learn and get better. cf the airline industry that gives the book its title.
https://www.goodreads.com/book/show/24611735-black-box-thinking
I'm surprised in this day and age that it relies on people reading and manually checking. I last worked actively in chemical distribution 10 years ago, but there were systems there where every drum was bar coded for product and batch number, the equivalent was on the pick sheet, and the operators had a handheld that you had to scan both on and would pick up any mismatch.
Just typed a long reply, and got 403 forbidden when I tried to post it.
So i'll split it into smaller chunks
To the pharmacists here, if there is no one to do that second check should the treatment not be dispensed or is it ok for it to be given?
It has to be ok, or in some places whole days would go by where no medicine could leave the pharmacy! As I've said before, there's a strong suggestion (which will probably appear in their SOPs) that if self-checking, you take a "mental break" and do something else to break your brain's chain of assumption between the 2 steps. It can be difficult, especially if you have an impatient patient watching you walk away from their tablets, but ignoring those pressures is part of working professionally.
Also I’m somewhat surprised to see a tick not an initial.
That's a squiggle, not a tick. They will know who makes that mark. It's difficult to get anything neat into the tiny boxes, not to mention writing it hundreds of times a day, so for most people, most of the time, it's squiggles... but we know whose squiggles they are!
he argues there seems to be a complacency or hubris in (some parts) of the medical community that means that these types of issues are just shrugged off as ‘these things happen’ rather than a desire to learn and get better.
To be fair, some people are like that. And the level of investigation we can realistically do, especially weeks after the incident took place, can be quite limited. So sometimes the best answer we can give is "these things happen/human error"... although we should then attempt steps to reduce the chances of it happening again.
There's a paragraph or 2 here about the pitfalls of computer checking. Seems to be the bit getting me the 403 for no reason I can see. So skip that!
And our problem (and Holy Grail) in pharmacy is, as I say to all new starters, "in pharmacy, perfection is just about acceptable." Everything needs to be 100% correct, 100% of the time. And even then, we will still get people complaining about something. I'm hoping the time I'm spending typing this helps people understand that perfection is not possible in any system that involves humans at any stage (someone has to program those computers, match the barcodes to the stock, etc) and so starting from a point of "strike 'em off!" is not helpful... it is even the opposite, as a fear of personal consequences for genuine human error leads to brushings-off and cover-ups rather than an open, learning, response.
And at the same time, I'm aware "lessons will be learned" is now perceived as a brush-off in its own right.
Here, though, there's enough suggestion from the pictures to say that this pretty definitely exceeds that... I'm afraid sometimes the investigation does throw up poor practise or negligence.
/end thread. I feel like I'm on twitter now!
it is even the opposite, as a fear of personal consequences for genuine human error leads to brushings-off and cover-ups rather than an open, learning, response.
which is also part of the Black Box premise - until culture changes so everything gets reported, then the culture remains of brushing off and cover up.
In the end the error is the error; once that happens the outcome is just luck. Reducing the seriousness of the investigation or corrective action because no-one actually got killed / seriously injured misses the chance to learn the lesson.
eg: H&S policy at work for example. If you fail to maintain a roof and a slate falls off and there's no-one there, it'll probably be marked down as 'oh, a slate clearly fell off, we'll bear that in mind next time we inspect the roof'. If it narrowly misses someone, it'll be dealt with straight away. If it hits and kills them......then the HSE are visiting and a world of pain. Same failure; what follows is pure damn luck and we shouldn't leave things to luck.
theotherjonv
In the end the error is the error; once that happens the outcome is just luck. Reducing the seriousness of the investigation or corrective action because no-one actually got killed / seriously injured misses the chance to learn the lesson.
eg: H&S policy at work for example. If you fail to maintain a roof and a slate falls off and there’s no-one there, it’ll probably be marked down as ‘oh, a slate clearly fell off, we’ll bear that in mind next time we inspect the roof’. If it narrowly misses someone, it’ll be dealt with straight away. If it hits and kills them……then the HSE are visiting and a world of pain. Same failure; what follows is pure damn luck and we shouldn’t leave things to luck.
I 100% agree.
Touch wood, I've never had any errors that had results as serious as this... but I'm fully aware, as are most pharmacists and I would say most other healthcare professionals, that it becomes a numbers game and a throw of the dice.
It's not flippant: perfection really is the minimum acceptable. I keep it in my head all day every day, constantly reviewing with a small part of me what might be done better/safer. But I'm also aware it's ultimately unobtainable.
Unfortunately (and it actually makes me a little sad), it's clear here that someone has let that mindset slip - whether briefly or routinely - and thereby caused others to suffer. Hopefully they will be able to learn and improve.
If anyone ever wonders why the pharmacy is taking so long - "it's only tablets" - please remember this thread and that there's a lot more going on back there than you may see!
Read this thread for a 3rd time now, and don't know what to say really.
Only what a huge cock up. I would defo report it and sue as well, Haloperidol is nasty stuff.
Hope the wife is ok now.
Some good advice from others here.
Good luck.
So someone else prepped an injection and someone else gave it?
This is why you don't give injections someone else has drawn up.
Haloperidol instead of B12. That's a good one!
Someone's not doing their 6 rights of medications.
This is why you don’t give injections someone else has drawn up.
Good luck vaccinating 65 million people 4 times each, over a period of a year or so.
Touch wood, I’ve never had any errors that had results as serious as this…
Whilst this is considered based on the "luck" of the error of the error not being immediately fatal it will never get better. Basically if someone dies or not is based on the alphabetic sorting and what lies to the left/right???
Whether someone dies or not should be irrelevant to the investigation because the potential exists both through not getting something a patient needs to stay alive or getting something that kills them.