THE PREVENTION OF ILLNESS AND INJURY COMBINED WITH THE DIAGNOSIS AND TREATMENT OF THE HUMAN RESPONSE IS THE EMBODIMENT OF WHAT NURSES DO AND WHO NURSES ARE AS HEALTHCARE PROFESSIONALS. ALONG WITH THIS GIFT THEY HAVE TO TOUCH THE LIVES OF THOSE WITHIN THEIR COMMUNITIES COMES A GREAT RESPONSIBILITY, WHICH INCLUDES PROVIDING PHYSIOLOGICAL AND EMOTIONAL SUPPORT FOR THE PATIENT.
IN TERMS OF PHYSIOLOGICAL AND EMOTIONALLY SUPPORT ONE MIGHT QUESTION IF ONE OUT WEIGHTS THE OTHER AND IF IT DID WHICH WOULD YOU CHOOSE? UNFORTUNATELY IN LATE AUGUST 2004 NURSE WILCOX CHOSE PUT HER EFFORTS SOLELY ON THE PSYCHOLOGICAL STATE OF HER PATIENT AND SHE FAILED TO FOLLOW A STANDING ORDER TO PROVIDE AN PROPHYLACTIC.
ANTIBIOTIC, WHICH RESULTED IN THE SUBSEQUENT INFECTION AND DEATH OF HER PATIENT MINDI TUCKER FOLLOWING A ROUTINE CAESARIAN SECTION. ON THE DAY OF THE INCIDENT THE PATIENT HAD COMPLICATIONS FROM A STREPTOCOCCUS-A INFECTION, WHICH DEVELOPED FROM A CAESARIAN DELIVERY OF HER CHILD AT BAPTIST HOSPITAL EAST IN LOUISVILLE, KENTUCKY. THE CLAIM OF MEDICAL MALPRACTICE IN THIS CASE REVOLVED AROUND THE FACT THAT THE ANTIBIOTIC CEFOTAN WAS NOT GIVEN DURING THE DELIVERY AS A PROPHYLACTIC.
AND MAY HAVE PREVENTED THE INFECTION FROM OCCURRING. THE HOSPITAL HAD THIS INITIATIVE IN PLACE AS A STANDING ORDER FOR CAESARIAN DELIVERIES AND RAISED THE QUESTION AS TO WHY IT WAS NOT GIVEN, WHO WAS SUPPOSED TO ADMINISTER THE DRUG, OR IF IT WOULD HAVE EVEN CHANGED THE OUTCOME. THIS CASE EXPLORES THOSE QUESTIONS IN DETAIL TO EXPLAIN HOW THIS INCIDENT TOOK PLACE AND WHY I BELIEVE THE NURSE MIGHT HAVE MADE FATAL ERROR THAT COULD HAVE BEEN AVOIDED.
JANET WILCOX, AN EXPERIENCED CHARGE NURSE OF OVER 25 YEARS, HAS HAD AN EXTENSIVE BACKGROUND IN LABOR AND DELIVER AND WAS ATTENDING WHAT SHE DESCRIBED AS ONE OF THE MOST DISTRESSED PATIENTS SHE HAS EVER SEEN THROUGHOUT HE CAREER. MINDI TUCKER, PREGNANT WITH 3 MEDICATION ERROR PAPER HER THIRD CHILD, WAS IN A STATE OF EXTREME PANIC DURING HER DELIVERY FOR REASONS THAT WERE NOT DISCLOSED DURING THE CASE.
THE PATIENT WAS ADMITTED DOCUMENTED RASH AND LABOR CONTRACTIONS EARLIER THAT DAY. THE PROSECUTION ARGUED THAT THE FAILURE TO GIVE THE CEFOTAN CAUSED THE DEVELOPMENT OF AN AGGRESSIVE INFECTION STREPTOCOCCUS-A. STREP-A, WHICH IS A GROUP B BETA HEMOLYTIC SPECIES FOUND IN RAW MILK, IS A LEADING CAUSE OF BACTERIAL SEPSIS AND MENINGITIS IN NEWBORNS AND MAJOR CAUSE OF ENDOMETRITIS AND FEVER IN POST PARTUM WOMEN.
INFECTED POSTPARTUM WOMEN DEVELOP LATE ONSET SYMPTOMS SEVERAL DAYS OR SEVERAL MONTHS AFTER GIVING BIRTH. SYMPTOMS INCLUDE SEPSIS MENINGITIS, SEIZURES AND PSYCHOMOTOR RETARDATION. NEONATAL INFECTION MAY BE PREVENTED BY DETECTING COLONIZATION BY THESE BACTERIA IN PREGNANT WOMEN AND BY ADMINISTERING ANTIBIOTICS PRIOR TO BIRTH (TUCKER V. WOMEN CARE PHYSICIANS OF LOUISVILLE, 2012).
ONE OF THE MOST COMMON ANTIBIOTICS USED BY THE HOSPITAL IN PARTICULAR WAS CEFOTAN. CEFOTAN IS A SEMISYNTHETIC BETA-LACTAM ANTIBIOTIC, CLASSIFIED AS A THIRD-GENERATION CEPHALOSPORIN AND IS GENERALLY LESS ACTIVE AGAINST SUSCEPTIBLE STAPHYLOCOCCI THAN FIRST GENERATION CEPHALOSPORINS ARE BUT HAS A BROAD SPECTRUM OF ACTIVITY AGAINST GRAM-NEGATIVE BACTERIA WHEN COMPARED TO FIRST AND SECOND GENERATION CEPHALOSPORINS (VENES, 2013).
FOR THE OBSTETRICIANS OF BAPTIST HOSPITAL EAST THE USE OF THIS SPECIFIC ANTIBIOTIC WAS PART OF A STANDING ORDER “ORDER 11”. A STANDING ORDER IS A WRITTEN DOCUMENT ABOUT POLICIES, REGULATIONS, OR ORDERS REGARDING PATIENT CARE AND GIVES NURSES THE AUTHORITY TO CARRY OUT SPECIFIC ACTIONS UNDER CERTAIN CIRCUMSTANCES, OFTEN WHEN A PRIMARY CARE PROVIDER IS NOT IMMEDIATELY AVAILABLE (BERMAN & SNYDER, 2012).
MORE THAN ALMOST DECADE BEFORE MINDI TUCKER WAS ADMITTED BAPTIST HOSPITAL EAST, THE HOSPITAL’S PATIENT CARE COMMITTEE AGREED UPON THE PROVISIONS OF THIS STANDING ORDER WHICH REQUIRES ALL C-SECTIONS HAVE 2 GRAMS OF CEFOTAN PREPARED FOR INFUSION AT TIME OF 4 MEDICATION ERROR PAPER CLAMPING. THE REASON AS TO WHY THIS WAS NOT DONE WAS DUE TO THE FACT THAT THE NURSE, BASED ON THE CLIENT’S STATE OF PANIC, WAS PREOCCUPIED WITH THE TASK OF ATTENDING THE PATIENT TO FULFILL HER DUTY TO RETRIEVE THE ANTIBIOTIC FROM THE FRIDGE AND HAVE IT PREPARED FOR THE ANESTHESIOLOGIST.
THE ANESTHESIOLOGIST IS ACTUALLY THE ONE WHO WOULD INFUSE THE DRUG THROUGH AN INTRAVENOUS SYSTEM. SHE WENT ON TO ELABORATE IN HER SPECIFIC DUTY DURING THE DEPOSITION AND HOW SHE WOULD NORMALLY GO TO THE REFRIGERATOR, ENTER THE PATIENTS CODE TO LOG OUT THE MEDICINE, SIGN THE MEDICINE OUT TO THE PATIENTS NUMBER AND THEN BRING THE MEDICINE TO THE PATIENTS OPERATING TABLE AND THE ANESTHESIOLOGIST WOULD ADMINISTER THE DRUG HOWEVER BASED ON THE CIRCUMSTANCES OF THE SITUATION THIS VITAL STEP WAS NOT DONE (TUCKER V. WOMEN CARE PHYSICIANS OF LOUISVILLE, 2012).
ALTHOUGH THE BABY WAS SUCCESSFULLY DELIVERED, THE PATIENT BEGAN TO SHOW SIGNS OR A RAPIDLY DEVELOPING INFECTION KNOWN AS STREPTOCOCCUS-A AND ALL EFFORTS TO CURE THE INFECTION FAILED. THE DEFENSE DURING THE CASE ALSO LOOKED INTO REASONS AS TO WHY THE DRUG MAY NOT HAVE BEEN ADMINISTERED.
IN THE MORTALITY REPORT DR. SUSAN BUNCH, WHO WAS THE OBSTETRICIAN IN THE PROCEDURE, STATED THAT IT THE REASON THE DRUG CEFOTAN WAS NOT ADMINISTERED AS A PROPHYLACTIC AT THE TIME OF THE PROCEDURE WAS BECAUSE OF THE PATIENT’S ALLERGY TO PENICILLIN. THIS IS ALSO THE REASON DR. BUNCH DID NOT QUESTION AS TO WHY THE MEDICATION WAS NOT SUPPLIED BY THE NURSE AT THE TIME AND THIS IS THE GRAY AREA OF THE CASE.
HAD THE MEDICATION BEEN GIVEN, TAKING INTO CONSIDERATION AN ALLERGIC REACTION, HYPERSENSITIVITY COULD HAVE ALSO BEEN A RESULT HOWEVER, THE NURSE SPECIFICALLY STATED THAT SHE SIMPLY FORGOT THE ORDER ALTOGETHER.
THE RESPONSIBLE ROUTE TO TAKE IN THIS SITUATION WOULD BE TO NOTE THE PATIENT’S ALLERGY TO PENICILLIN AND REQUEST AN ALTERNATIVE MEDICATION SUCH AS KEFZOL WHICH COVERS WIDE RANGE OF BACTERIA AND IS NOT AS EFFECTIVE BUT IT WAS AN 5 MEDICATION ERROR PAPER OPTION THAT HAS BEEN USED BY OTHER OBSTETRICIANS IN THE SAME HOSPITAL. THE OTHER DEBATABLE FACTOR IS THE RESPONSIBILITY TO PROVIDE THE DRUG. DR.
BUNCH WHO WAS PRESENT DURING THE PROCEDURE DID FULFILL HER OBLIGATION BY ORDERING THE DRUG, WHICH WAS DOCUMENTED AS “STANDING ORDER #11” BUT HE WAS NOT IN CHARGE OF ADMINISTERING THE DRUG. THE ANESTHESIOLOGIST WAS ANOTHER PROFESSIONAL PRESENT AND WAS IN CHARGE OF ADMINISTERING THE DRUG CEFOTAN THAT IS TO BE PREPARED FOR ADMINISTRATION BY THE NURSE.
NURSE WILCOX AT FIRST, DESCRIBED HER DUTY AS BEING FULFILLED BECAUSE THE DRUG WAS NOT A MIXTURE OF ANY TYPE SO IN THAT CONTEXT IT WAS PREPARED.
THROUGH FURTHER QUESTIONING IT WAS DETERMINED THAT STATUS OF THE MEDICATION DID NOT ESCAPE THE FACT THAT IT WAS NOT PROVIDED TO THE ANESTHESIOLOGIST AS THE ORDER REQUIRED BY THE NURSE AND WAS DETERMINED THAT THE FAULT RESTED ON HER FOR NOT COMPLETING THIS ONE TASK. IT WAS ALSO DECIDED THAT DR. BUNCH COULD NOT BE HELD LIABLE FOR THE OVERSIGHT DUE TO A PREVIOUS COURT RULING.
SEE NAZAR V. BRANHAM, 291 S. W. 3D 599, 607- 08 (KY. 2009) HOLDING THAT “A SURGEON WAS NOT VICARIOUSLY LIABLE FOR THE NEGLIGENT ACTS OF THE NURSES IN THE OPERATING ROOM” (NAZAR V. BRANHAM, 2009).
THE SIX RIGHTS OF MEDICATION ADMINISTRATION IS ESSENTIAL FOR SAFETY AND ACCURACY AND IS A STANDARD OF PRACTICE PUT INTO PLACE IN ORDER TO AID IN THE PREVENTION OF MEDICATION ERRORS THAT WOULD OTHERWISE BE AVOIDABLE. THESE RIGHTS INCLUDE THE RIGHT DRUG, RIGHT DOSE, RIGHT ROUTE, RIGHT TIME, RIGHT PATIENT, AND RIGHT DOCUMENTATION (KARCH, 2013).
BY LOOKING AT EACH OF THESE RIGHTS INDIVIDUALLY AND COMPARING THEM TO THE FACTS UNDERLYING THE CASE YOU CAN SEE WHAT STEPS COULD HAVE BEEN DONE DIFFERENTLY TO PREVENT THIS OVERSIGHT. FOR EXAMPLE RIGHT DRUG MAY OR MAY NOT HAVE BEEN CEFOTAN DUE TO THE PATIENT’S ALLERGY BY REFERRING THE MAR, WHICH IS ONE OF THE FIRST CHECKS IN MEDICAL ADMINISTRATION, COULD HAVE REVEALED THAT.
A CULTURE SENSITIVITY TEST MAY HAVE BEEN DONE TO DETERMINE THE EXTENT OF 6 MEDICATION ERROR PAPER HYPERSENSITIVITY TO THE DRUG AND IF THE RISK WAS TOO HIGH, ANOTHER MEDICATION MIGHT HAVE BEEN POSSIBLE. PERTAINING TO THE RIGHT DOSE AND ROUTE, IF THE MEDICATION NEEDED TO BE SUBSTITUTED THEN THE ROUTE AND DOSE MIGHT BE CHANGED FOR PROPER ADMINISTRATION.
THE RIGHT TIME WAS SPECIFICALLY STATED IN THE STANDING ORDER, WHICH REQUIRED IT TO BE PROVIDED BY THE NURSE TO THE ANESTHESIOLOGIST AT THE TIME OF CLAMPING FOR THE RIGHT PATIENT MINDI TUCKER. THE LAST RIGHT IS KNOWN AS RIGHT DOCUMENTATION AND THIS WAS THE DECIDING FACTOR OF THE VERDICT. DR.
BUNCH DOCUMENTED THE ORDER FOR THE NURSE TO PREPARE THE MEDICATION;
AT THIS POINT THE NURSE WOULD HAVE ENTERED THE PATIENTS CODE INTO THE REFRIGERATED STORAGE AND AUTOMATICALLY CHARGE IT TO THE PATIENTS RECORD. DUE TO THE MENTAL STATE OF THE PATIENT, NURSE WILCOX ADMITTED THAT SHE WAS DISTRACTED, FORGOT TO PREPARE THE MED, AND THE ANESTHESIOLOGIST HAD TO DOCUMENT THAT NO ANTIBIOTIC WAS PROVIDED BY THE NURSE FOR ADMINISTRATION. GIVEN THE 25 YEARS EXPERIENCE IT MAY BE A STRETCH TO PORTRAY THIS NURSE AS INCOMPETENT HOWEVER, THE FAILURE TO FOLLOW THE PROPER PROCEDURE RESULTED IN THE LOSS OF LIFE. UNFORTUNATELY FOR NURSE WILCOX THE RESPONSIBILITY FELL INTO HER HANDS AND ENDED THERE WHEN SHE DEVIATED FROM THAT STANDARD OF PRACTICE.
7 MEDICATION ERROR PAPER REFERENCES COMMITTEE ON IDENTIFYING AND PREVENTING MEDICATION ERRORS; ASPDEN P, WOLCOTT J, BOOTMAN L, CRONENWETT L, EDS. CROSSING THE QUALITY CHASM: A NEW HEALTH SYSTEM FOR THE 21ST CENTURY. WASHINGTON, DC: NATIONAL ACADEMIES PRESS, INSTITUTE OF MEDICINE; 2001. BOND CA, RAEHL CL, FRANKE T. INTERRELATIONSHIPS AMONG MORTALITY RATES, DRUG COSTS, TOTAL COST OF CARE, AND LENGTH OF STAY IN UNITED STATES HOSPITALS:
SUMMARY AND RECOMMENDATIONS FOR CLINICAL PHARMACY SERVICES AND STAFFING. PHARMACOTHERAPY 2001;21(2):129-41. KARCH, A. M. (2013). FOCUS ON NURSING PHARMACOLOGY (VOL. 6). PHILIDELPHIA, PENNSYLVANIA: LIPPINCOTT WILLIAMS & WILKINS. NAZAR V. BRANHAM, 2004-SC-001015-DG, 2005-SC-000834-DG.
(SUPREME COURT OF KENTUCKY APRIL 23, 2009). TUCKER V. WOMEN CARE PHYSICIANS OF LOUISVILLE, 2010-SC-000466-DG (SUPREME COURT OF KENTUCKY OCTOBER 25, 2012). VENES, D. (2013). TABERS CYCLOPEDIC MEDICAL DICTIONARY (VOL. 22). (B. G. FENTON, ED. ) PHILIDELPHIA, PENSYLVANIA: F. A. DAVIS COMPANY. 8.