So what happens now?
The quality assurance department in the hospital will perform a root cause analysis to investigate all components of the extant procedure for medication delivery of heparin to infants in the neonatal intensive care unit. AIt will interview the pharmacists, physicians, pharmacy technicians, nurses and any other staff memebers invovled in the process at any point.
It will attempt to find weaknesses in the process, weaknesses in the education of the staff, reasons for noncompliance with the policy and procedure to administer medications, and then it will make receommendations to hospital committees charged with determining the policy and procedure for medication administration of this type.
Outside agencies will also become involved. The two infants that died will be under the jurisdiction of the coroner to determine the cause of death and contributing factors, and to refer the cases to law enforcement if there is suspician of criminal intent or action.
The state department of public health may become involved to investigate safe drug handling and administration practices.
The cases may go to litigation.
The nurses are most likely devastated and should be supported and be receiving counseling.
Their nursing licenses may be investigated, and if found negligent, the licenses may be suspended, revoked or be placed under restrictions or sanctions.
The national hospital accrediting body, the Joint Commission for Accreditation of Healthcare Organizations, JCAHO, will include the incident, investigation and subsequent actions to address the weaknesses in the policy and procedure in its routine survey to dtermine accreditation status.
But in the end, it boils down to nurses not taking shortcuts, nurses safeguarding patients, and nurses standing up for patients' rights in the face of poor work practices, poor working conditions and inadequate resources.
Wednesday, September 20, 2006
Another Medical Misadventure/Quality Issue
I came across an interesting blog post. While this was posted in response to the babies who died in Indiana because of an error in heparin dosing (11 doses were given among the babies, so not a singular event), the last section of the post pertains to our case that I wrote about a couple of days ago.