Ms. E, aged 28 years, often woke up in the middle of the same nightmare, soaked in sweat and out of breath with her heart pounding. She would remind herself that it was only a dream, but each night felt as realistic as when the incident actually happened.
In her nightmare, Ms. E would walk the hall of the hospital where she had worked for the past 10 months as a physician assistant in the orthopedic department. She saw herself from outside her own body, walking into a patient’s room, greeting him and speaking to him briefly before reaching for the syringe on the cart next to his bed.
Ms. E frantically tried to rouse herself from the dream before the next part happened, but she could never break free. She tried to stop her dream self from using the syringe, but could only helplessly watch in horror as the needle went into the patient’s shoulder and the plunger of the syringe was pushed.
“No!” she yelled, finally breaking free of the dream and bolting upright in bed. As usual, she was shaking and filled with remorse. It would be months before she would have a sound night’s sleep again. The actual incident had been much like her dream. The job with the hospital had been her first as a PA, and in the months that she had been working there she’d learned a great deal and often felt overwhelmed.
The orthopedic department was usually filled with patients, and Ms. E was quite busy. Sometimes she felt that she was being pulled in too many directions at once, with different physicians asking for her assistance throughout the day.
On the day that the error occurred, Ms. E had been asked to give Mr. J, aged 76 years, an injection of a local anesthetic. Mr. J was in the clinic for shoulder surgery. Ms. E walked in, exchanged brief pleasantries with the patient, and then picked up the syringe from the cart next to his bed.
“This will only hurt for a second,” she told him as she pressed down on the plunger.
It only took a moment for Ms. E to realize that what she had injected into Mr. J was not an anesthetic. He began having trouble breathing and was holding his chest.
“My heart is racing,” he wheezed.
Ms. E grabbed the syringe to look for a label, but it was unmarked. She called to a passing physician who ran in and began irrigating the shoulder in an attempt to get the medication out.
“What was it?” the physician asked. “It seems like epinephrine.”
“I don’t know,” said Ms. E. “I thought it was an anesthetic. I didn’t stop to look at the label, and it’s unmarked. I’m so sorry!”
“It’s epinephrine,” said the physician as he worked to get as much of the drug out of the patient as possible.
Despite the efforts of the physician and Ms. E, as well as some other clinicians who ran in to help, Mr. J suffered a heart attack.
Luckily, the patient survived, and did not sue Ms. E or the hospital. However, Ms. E’s problems were far from over.
The patient filed a complaint with the state department of health, and the state board of medicine began an investigation. In the meantime, Ms. E had numerous debriefs with her supervisors and was temporarily placed on administrative duty and removed from patient-care activities.
Ms. E felt terrible about what had happened, and expressed this repeatedly to her coworkers, her supervisors, and the patient and his family. She spent a great deal of her time, both at work and at home, going over what had happened, analyzing her mistake, and thinking of ways in which patient safety could be improved and errors prevented in the future. By the time a month had passed, Ms. E had come up with a list of improvements that she felt could be implemented at the facility, and she presented the list to her supervisor.
“I know that I made a terrible error,” she told her supervisor. “The mistake was my fault. I should have looked at the syringe carefully. I should have checked the label. I know this. And I will never do anything like that again. But I think there are other ways that patient safety can be improved, and I would like to be a part of that.”
The supervisor looked at the list and agreed that Ms. E had come up with some excellent suggestions. But the complaint against her was still pending, and her future at the clinic would remain in limbo until it was resolved.
After a thorough investigation, the health department reported to the state medical board that Ms. E had failed to meet the standard of care by administering the wrong medicine, but that she had immediately recognized and reported the error, and had since been proactively involved in developing procedures to ensure that no such errors would happen again.
Ms. E and the health department worked out at settlement that was approved by the state medical board. Under the terms of the settlement, Ms. E was required to give a one-hour lecture on preventing errors, would pay a $5,000 fine, would pay investigative costs and would take five hours of continuing education in risk management. Ms. E also received a letter of concern on her record.
Patients don’t always sue when an error occurs. Sometimes they don’t feel it is worth the effort. Sometimes an attorney advises them against bringing suit. And sometimes, as possibly happened here, a patient recognizes that a mistake was made and that the clinician is deeply and sincerely sorry. Even if a patient doesn’t choose to pursue a lawsuit, however, the clinician may still face action by the state’s health department or medical board.
Obviously, you should never administer any medication — whether by subcutaneous injection, orally, or intravenously — without first checking to make sure that you are administering the right drug and dosage.
Ms. E recognized as soon as the error occurred that she should have checked the syringe label. Had she looked at the syringe prior to using it, she would have noticed that there was no label on it, and she would not have used it. Clearly, someone other than Ms. E was also at fault in this case for allowing an unmarked syringe to be sitting out in a patient’s room.
Although, luckily, the patient recovered from the error, it could have been fatal. Ms. E will no doubt be extraordinarily careful in the future, but it shouldn’t take this sort of mistake for that to happen. No matter how busy, rushed, or harried you are, always check medications before administering them to patients.
Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.