Friday, February 25, 2011

Mother dies after nurse makes error administering drug

Article from the Daily Mail 23 February 2011

In true Daily Mail style the story is hyped under the title "Mother-of-four dies after blundering nurse administers TEN times drug overdose"

80 year old Arsula Samson died on 14 March 2010 at Good Hope Hospital, Birmingham after she was given an overdose of deadly potassium chloride.

According to the inquest staff nurse Lisa Sparrow wrongly administered 50ml of the drug over half an hour instead of over five hours, the inquest heard.

Instead of pressing the 10ml per hour button, the nurse admitted tapping in 100ml per hour on the drug infusion pump.

Staff nurse Sparrow signed out the medication from the controlled drug stock cupboard with staff nurse Susan Smith, as two people were supposed to administer and check the drug together to avoid any errors under hospital policy.

But nurse Smith left nurse Sparrow to give the drug on her own when the error happened. The coroner said that nurse Sparrow's gross failure resulted in the overdose and was a direct cause for the death while a second failure was that nurse Smith did not oversee the drug being given.

Mrs Samson was suffering from pneumonia when she was given the massive overdose that led to her death

Mrs Samson was suffering from pneumonia when she was given the massive overdose that led to her death

Nurse Sparrow told the inquest she had not expected nurse Smith to watch her give the potassium as 'no-one ever did'.

An official Trust report said no error was found with the infusion pump and investigators ruled the death was due to 'individual, human error'.

A Trust action plan after the death saw new infusion pumps and software that reduce the risk of error brought into all wards, medical staff retrained and warned over the dangers of potassium chloride and advice on the importance of a second nurse witnessing medication being given.

Birmingham coroner Aidan Cotter gave a verdict of accidental death to which neglect contributed.


Bonnie Hughes said...

I feel disgusted and insulted that you comment that the Mail have "hyped the story with the headline it has used". It is the truth and if you were to read/hear the transcript you would hear two very experienced high grade nurses who work in critical care admit they did not know what they were supposed to do with dangerous drugs. Heart of England Trust is killing people and NOT learning from their mistakes. They were not short staffed, bank nurses or any other excuse they usually use, the were both incompetent nurses who considering they work in a caring role showed little or no compassion for taking my Mothers life on Mothers Day. Take a look at Cure the NHS-Heart of England, Justice4Stephen or read Lisa Richards-Evertons story. All the same stories of incompetent nurses who did not follow laid down procedures and hospital policy/protocol , yet little or no disciplinary action taken. Legalised euthanasia by the NHS.

Yours disgustedly

Bonnie Hughes

Human factors in risk management said...

Sorry if I offended you. I hope you can see that my blog post did clearly show that errors had a tragic consequence.
I'm afraid that I only have the information published in the Mail. This suggests to me that a nurse made a simple mistake but there was no device or system in place to warn about what had happened or reverse the consequences.
The fact that the nurses involved were 'very experienced high grade' (as you say) I'm not sure how they can be labelled as 'incompetent.' Even the most competent people make mistakes, which is something any organisation needs to understand so that they can protect against it.
Thanks for taking the time to leave a comment. Once again, I am sorry for any offence.

Bonnie Hughes said...

Hi Andy,
It is just very raw as they were experienced in" years" but were incompetent as they did not follow laid down policy and procedures when dealing with dangerous drugs, they freely admitted that no-one ever did. They are dealing with lives, their errors/omissions are costing lives. However if an audit was done the paperwork would show that they all did what they were supposed to, the double check at point of administration. How can any organisation protect against staff who deliberately fail to follow policy/procedure when they do not have a robust disciplinary policy. Mistakes with lives cannot be corrected. Thankyou for your reply, sorry if I was confrontational. Bonnie

Human factors in risk management said...

It's good for me to be reminded that these stories are not just examples of systems that go wrong, but have real human implications.