Medication Mistakes, a Sobering Thought

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VaccinationI read the breaking news headline as the tragedy began to unfold: A medication mistake at a local hospital resulted in the death of an infant. Small details were revealed over the next number of days until eventually the story was pieced together. A nurse, acting in haste, didn’t realize that two patients were to receive the same medication in the ER but with one vital difference: One bag of medication contained an adult dose while the other contained an infant dose. The nurse grabbed the wrong one and about 10 minutes after administration, the infant went into cardiac arrest and succumbed to this fatal error.

My heart went out to the family, but it also went out to those involved in the infant’s care; yes, even the nurse, especially the nurse. Mistakes are sometimes made, and when we make the decision to enter into the healthcare field, we must realize that mistakes can have dire consequences and that it is our duty to make every effort to avoid such mistakes regardless of pressures we may be facing, whether running against the clock or dealing with a family crisis or just feeling temporarily uninterested in our work; we cannot afford a lapse in judgment.

As a medical language specialist, you might be reasoning that any mistakes made within the medical report that could lead to life-threatening errors are ultimately the responsibility of those directly involved with patient care: doctors, nurses, specialists, surgeons, pharmacists, and so on. You might reason that a report signed off by a doctor—whether electronically or otherwise—becomes that doctor’s responsibility or that gross errors should easily be caught by hospital and clinic staff prior to active patient care. Let’s assume that’s true, as I want to touch on a more personal note spurred by my compassion for that nurse.

The nurse, likely trying to ensure quick care of patients in critical condition, omitted a small but crucial step in hospital protocol—that of double-checking the medication, including the dosing information, typed out on the bag’s label. Now for the rest of their life, this nurse will remember that day and feel a very heavy heart of guilt due to an unintended act of negligence. That is a very heavy burden to bear.

With that in mind, let’s consider ourselves, and be honest now. Have there been times when you were rushing to complete a report because it was past TAT and failed to bother double-checking medications and corresponding doses? Or have there been times when your line count was suffering so you started to omit critical steps in double-checking your work? Or have there been times when you erred on the side of carelessness rather than caution in order to avoid having to flag a report? Really be honest.

While there is a greater chance that someone directly involved in patient care might make a critical error, we don’t want to diminish the importance of accuracy on the part of the medical language specialist. Choosing to ignore important steps in capturing the patient record, including ignoring critical dictator errors or simply not being diligent enough to notice them, could, in all reality, contribute to the detriment of the patient’s care. By the same token, flagging a critical dictator error could aid in preventing a medical calamity (though don’t expect to get a pat on the back for it).

To that end, always remember that behind all those transcribed words is a real person—someone relying on others to boost their quality of life, whether in a seemingly nonconsequential setting or in the face of a life-or-death situation. Remember to treat them with the utmost of care and to the best of your ability, always.


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  1. Valerie August 09, 2016

    Hello and thank you for this post. I am new on the MT Program and came across this. Sobering indeed but my real take-away is the understanding of an MT’s responsibility. Thank you for emphasising this!

    Best wishes,

    Val.


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