Stop Pointing Fingers - Medical Errors

The usual response to an error made in health care is defensiveness, which includes finger pointing, guilt and sometimes cover-up.

No one wants to think they could have made a mistake that could harm a patient. Recently, I experienced that feeling.

A 43-year-old female patient with a history of insulin-dependent diabetes, coronary artery disease and congestive heart failure underwent an outpatient angiographic procedure to correct a blockage in a lower extremity. During the procedure she received medication for sedation over a 3-hour period and vital signs were being monitored. Post-procedure she was transferred to a stretcher and wheeled to the hall for transport to a nursing unit.

At this time, she was awake and oriented and complaining of nausea. I administered the 25 mg of Phenergan® (promethazine HCl, Wyeth-Ayerst) IV ordered by the physician. The patient was not being monitored, nor was she on oxygen therapy. She was then transported to the nursing unit, where I gave report and then returned to my department.

A short time later, my director asked me to explain what happened to the patient. When I gave him a questioning look, I was told the patient became unresponsive, with an O2 saturation of 68 percent, and narcotic and sedative antagonists needed to be administered.

An event report was written and submitted to our risk manager. When questioned, my first reaction was to become defensive, and then I felt guilty. What did I do? Or not do? There were several factors involved. How much sedative was given? The 25 mg of Phenergan was a normal dose, but did it potentiate the drugs already administered? I was asked why the patient's pulse oximetry wasn't being monitored during transport. It was also questioned whether or not I had instituted an unsafe medication order given by the physician.

Denise Barnett, RN, CLHRM, CPHQ, the risk manager at Charlotte Regional Medical Center, Punta Gorda, FL, stresses a team approach to the improvement process. She counseled me to view the event as an educational opportunity. What could we have done differently or better?