Avoiding Medication Errors and Sentinel Events
I suspect few words would bring a cold sweat to a pharmacist or nurse quicker than, “Do you remember that IV? Well there was a mistake.” IV medications have a definite finality to them since they get pumped directly into a patient’s blood stream. The margin for error can be ever so small. Getting it wrong could mean the death of your patient. The fact that a pharmacist or clinician could actually go to jail for such a mistake is a relatively small thing compared to the loss of a life.
Shortly after I started at KLAS, I came across a well-publicized, heartrending story about an IV medication error involving a little girl named Emily Jerry. What really drove home the story is that at the time I read it, my little girl was about the same age as Emily.
Emily, at the tender age of 18 months, had been diagnosed with a cancerous tumor in her abdomen that was about the size of a grapefruit. It was decided that she would undergo chemotherapy treatments. Emily responded well to the treatments, and the tumor began to shrink. After a five-month series of chemotherapy, tests showed absolutely no signs of cancer in her body; there wasn't even the expected residual scar tissue from the large tumor. However, to be sure that nothing was missed, the doctors decided to put Emily through one final series of chemotherapy, the last treatment of which would take place on her second birthday. Little Emily would be celebrating not only her birthday but also a win in her battle against cancer.
On the day of her last treatment, tragedy struck. The technician mixing the IV medication made an error. Instead of being mixed in a bag of less than 1% sodium chloride, the medication was inexplicably mixed in a bag of over 23% sodium chloride—a fatal dose for a child as small as Emily. Tragically, the error wasn’t caught; no person or system noticed it before the dose was administered. Shortly after the medication was started, Emily’s condition declined dramatically. Within an hour she was put on life support and two days later she died.
Any medication error, especially one as tragic as a sentinel event like Emily Jerry’s, is something no provider wants on their hands. For this reason, KLAS will continue to report on technology that makes patients safer and supports providers and will continue to highlight vendors who are driving excellence.
Emily’s dad, Chris Jerry, believes that had an IV workflow management system been in place during his daughter’s last treatment, Emily would have lived. KLAS is collecting data for a study on IV robots and IV workflow management solutions. We would love to get your perspective on solutions that you currently use, ones that you are considering, and ones that you have ruled out. To share your experience and get a copy of the report, email me at paul.hess@klasresearch.com.
After Emily’s death in 2006, Chris Jerry started The Emily Jerry Foundation (EJF) to bring awareness to lifesaving technologies and practices that reduce preventable medical errors. I am pleased to announce that KLAS and EJF will be working together on this IV compounding technology research in an effort to provide clarity around these technologies. To support and learn more about the Emily Jerry Foundation, visit their website.
What other reports should KLAS do to make a difference in healthcare? Offer your suggestions and opinions below.