A page from Deanna’s Journal

Last night I was waiting for my patient to return from Xray confirming his epiglottitis. (Major stuff. Could lead to death d/t airway closing up). The Dr. had his results already and the pt was going to be admitted to the acute ED and from there to a critical floor. Note, he was awake, talking and not acting as if he was about to stop breathing BUT, with the swelling of the epiglottis…it can (and does) become an acute and critical situation very quickly.

The patient returned from Xray in a wheelchair and was wearing a surgical mask. He was put in the reception room, where there were a couple of our other patients as well. I knew he had come back because the transportation tech told me he’d put him there. The Dr. looked through the reception window at him and said “Good, he’s back. Here are the orders. ” (IV, lots of labs, blood cultures, NPO status, and an antibiotic shot)

In our ED, we have a program where med students are available to “line and lab” patients in order to give them hands-on experience. I got the supplies for the IV start and labs, and some labels to both identify the patient and to label the blood samples and went to get the patient. I saw through the window that another med student was already lining and labbing him. “Ok, that’s weird” I thought, since I had the order sheet in my hand, and as far as I knew, no one else knew what he needed.

The patient had a big surgical mask on, all that you could see were his eyes. I had only seen him briefly before, so I didn’t really know what he looked like. I went and asked the med student if this was Mr. Jones. “No, this is Mr. Smith” she said as she worked on starting the IV, and pointed to the gentleman’s med sheet on the table next to her. Indeed the med sheet said Mr. Smith.

Hmm…. Maybe I was wrong and Mr. Jones wasn’t put in reception. I looked in each exam room, and found no Mr. Jones. I asked the other nurses if they had seen Mr. Jones? No one had seen him. During this time, the med student was still in reception working on “Mr. Smith”. Finally I asked the Dr. if he’d moved the patient somewhere else. The Dr. said “No, he is right there” pointing through the window at “Mr. Smith” and the med student. I went back to reception and looked at the patient’s wristband. Sure enough, it said Mr. Jones. I asked him to verify his birthday and his last name. This patient is truly the elusive Mr. Jones, and not the Mr. Smith that the med student thought she was lining. The med student looked like she was going to faint. I told her it was fine. Mr. Jones needed the line and labs, just finish and not worry.

If only it had ended there. I picked up Mr. Smith’s med sheet and left the correct one, the med sheet for Mr Jones. After I walked out of the room, I saw that a medication on Mr. Smith’s med sheet had been signed off by a nurse as having been given to Mr. Smith. This normally would not have alarmed me, EXCEPT it was given during the time that the med student (and presumably the other nurse) thought that Mr. Jones was Mr. Smith.

I located the nurse who’d administered the medication. She said “What do you mean that is not Mr. Smith?” We rush back to the patient and the med student. The other nurse said “You aren’t Mr. Smith?” Pt says “Why no, I’m Mr. Jones.” Another pt in the rooms says “I’m Mr. Smith.” The nurse now looked like she might faint. I took her out of the room. She did, in fact, give the wrong med to the wrong patient. Luckily the med itself wasn’t a huge issue. It was ibuprofen BUT, the wrong patient got it! More importantly, the patient who is supposed to have nothing by mouth because of the risk of throat swelling and occluded breathing, was given a pill. To swallow. The med student looked like she was going to cry. Both men needed lines, so that was okay. But, if she’d succeeded in obtaining the labs before the mix-up was identified, she would have sent the wrong labs on the wrong patient with the wrong labels and it could have been bad. She didn’t. So count that as a near-miss. Now the nurse in question… she gave the wrong med to the wrong patient. Not a near miss. A real med error. If that nurse had taken the 10 seconds to look at the patient’s wristband and verify he was who she thought he was…it would not have happened. But she didn’t and so it did. All were wrong in this case. The nurse in question got lucky… the patient did not have an adverse reaction, but the potential was there. Know your patient, and verify their identification EVERY TIME. That nurse and patient got lucky. That may not be the case next time.

Remember:
Right med
Right patient
Right dose
Right route