An article, “How Medical Staffs Can Learn From the Mistakes of Others” published on HealthXPert.org, refers to the Joint Commission Journal on Quality and Patient Safety’s publication that exposed the 2006 death of a pregnant teen at a Wisconsin hospital.
The article reports that the death came after a nurse “intending to administer penicillin, instead hooked up a look-alike bag of anesthetic—meant to be delivered later by epidural route only—through [the nurse’s] IV.”
Looking to learn from hospital errors, the article points to “general recommendations that could be used in any hospital where medication mistakes are a danger because of look-alike packaging or a chaotic environment.” Those included using different shaped or sized containers to differentiate IV meds from epidurals, and applying warning labels to both sides of an epidural bag and over the access port used to spike the bag.
