This week’s Sunday Scribblings prompt was to write anything about instructions. What immediately came to my mind was the news story about the three newborn infants that were given the wrong dose of medication and didn’t survive...all due to a “mix-up” when in actuality, it was because instructions weren’t properly followed.
I have worked in the medical field in hospital laboratories and instructions are a vital part of any hospital in any department. You follow instructions to the letter. You do not deviate. You do not become distracted. You check and double check and have others check your work. You can directly kill a patient if you don’t follow instructions. That is what happened to these tiny infants. Not only did the pharmacy technician not follow proper instructions, the nurses didn’t follow proper instructions.
“The nurses didn't realize a pharmacy technician had mistakenly stocked the cabinet with vials containing a dose 1,000 times stronger than what the babies were supposed to receive. And they apparently didn't notice that the label said "heparin," not "hep-lock," and that it was dark blue instead of baby blue.”
How could this happen? More than one person in a neonatal intensive care unit did not follow instructions. Now, don’t get me wrong, I am not saying that I have never made a mistake while working but because we check and double check and have others check our work, the mistakes I have made have been picked up before ever leaving the lab.
This makes me sad for those families affected as their children didn’t have to die. This makes me sad for the hospital staff as they will never forget that all they had to do was follow instructions.
I have worked in the medical field in hospital laboratories and instructions are a vital part of any hospital in any department. You follow instructions to the letter. You do not deviate. You do not become distracted. You check and double check and have others check your work. You can directly kill a patient if you don’t follow instructions. That is what happened to these tiny infants. Not only did the pharmacy technician not follow proper instructions, the nurses didn’t follow proper instructions.
“The nurses didn't realize a pharmacy technician had mistakenly stocked the cabinet with vials containing a dose 1,000 times stronger than what the babies were supposed to receive. And they apparently didn't notice that the label said "heparin," not "hep-lock," and that it was dark blue instead of baby blue.”
How could this happen? More than one person in a neonatal intensive care unit did not follow instructions. Now, don’t get me wrong, I am not saying that I have never made a mistake while working but because we check and double check and have others check our work, the mistakes I have made have been picked up before ever leaving the lab.
This makes me sad for those families affected as their children didn’t have to die. This makes me sad for the hospital staff as they will never forget that all they had to do was follow instructions.
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1 comment:
I was horrified when I saw this on the news!
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