Accidents
Advocate Luthrean Hospital
Summary:
An infant boy died after a series of medical errors: incorrect information was entered into an electronic intravenous order; automatic alerts had been turned off; and a bag was mislabelled.
Details:
A Chicago hospital paid $8.25 million to settle a lawsuit brought by the parents of an infant boy who died at the institution in October 2010 after a series of medical errors.
The mother gave birth to her son 4 months prematurely. She stayed by his side with her husband for the next six weeks while the boy remained in the hospital’s care. On 15 October, the baby suddenly died after coming out of a heart operation without any clear complications.
The hospital determined that a pharmacy technician had entered information incorrectly when processing an electronic Intravenous (IV) order for the baby. This resulted in an automated machine preparing an IV solution containing a massive overdose of sodium chloride, more than 60 times the amount ordered. The problem would have been identified by automated alerts in the IV compounding machine, but these were not activated when the customised bag was prepared for the baby. That is, adaptation data had been used to change the behaviour of the machine.
Investigations also found that the outermost label on the IV bag administered to the baby did not reflect its actual contents. Furthermore, although a blood test on the infant had shown abnormally high sodium levels, a lab technician assumed the reading was inaccurate. This highlights a different perspective on the dangers of defaulting, in this case a default assumption rather than a numerical default value.
Since the incident, staff have been activating alerts for similar IV compounders used in the system’s hospitals and strengthened “double check” policies for all medications leaving pharmacies.
This incident highlights the importance of the integrity and verifiability Data Properties, for example with regard to: the information in the IV order; the bag label; and the blood test results.
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