Third Baby Dies After Error at Indiana Hospital, Essay Example

In the article by Kim & Webber (2006), several flaws were identified within the process that led to the death of three infant patients. The flaws are as follows: 1) A technician delivered heparin vials in adult dosages to the neonatal unit; 2) The affected infants were given these adult doses, which is the equivalent of a dose 1,000 greater than was actually prescribed; and 3) There was little to no attention paid to the delivery of the wrong type of vials to the unit, nor did any nurses pay attention to what they were administering to these patients.

For each process flaw, the following strategies must be considered in order to minimize errors and risks to patient health as best as possible: 1) Technicians who deliver medications to the neonatal unit must recognize the differences between adult doses and infant doses and properly label all vials accordingly; 2) All nurses must carefully examine these vials prior to administering any medications to patients and immediately address any errors in the doses; and All nurses and technicians who handle medications in any capacity must be provided with comprehensive education, training, and continuous oversight in order to prevent these types of errors from occurring in the future.

These strategies are practical in nature and realistic, and they demonstrate the need to develop effective protocols that are strict in nature and that must provide detailed instructions for all personnel to follow. At the same time, distractions must be minimized when dispensing and reviewing medications, including the prohibition of cell phone use during these steps, along with any other elements that may cause distractions among staff members when medication administration and/or delivery are part of their daily responsibilities. This is an important starting point in order to ensure that patients receive the best possible attention and focus without the risk of preventable errors.

References

Kim, T, & Webber, T. (2006). Third baby dies after error at Indiana hospital. USA Today, retrieved from http://usatoday30.usatoday.com/news/nation/2006-09-20-baby-deaths_x.htm