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Kansas Association of Broadcaster’s Radio Feature Award Winner-2008.
This is a 3 part series aired during “Patient Safety Awareness Week”. March 3-5, 2008 on 580 WIBW Radio, Topeka, KS by Jim Doblin.
Since airing the stories, the KS Board of Nursing has agreed to more carefully scrutinize nursing negligence cases.
Monday, March 3, 2008
Patient Safety Awareness Part 1
Glenda Rodgers watched as her pregnant daughter Robin and her future granddaughter…died in a matter of hours at a Manhattan hospital after a nurse made a critical mistake.
What happened that summer day in 2006 was this: Robin Lowe 8 months pregnant with a history of stomach problems enters the hospital dehydrated, is put on pain medicine, and, in the process of weaning her off the pain meds so she could deliver the baby, is fed what nurse Susan Meeker thinks is IV solution.
Glenda says almost immediately her daughter was in severe discomfort, and as the hours ticked by...she watched, helplessly, as the baby died and then, her daughter.
To Glenda, a registered nurse herself, it was unthinkable.
But just as unthinkable to Rodgers now, is the fact that the nurse entered what amounts to a no-contest plea with the state board of nursing and was allowed back to work in just 8 months.
Tomorrow, what the state board of nursing has to say about all of this and why officials say the system works to protect the patient and educate the professionals.
Kansas State Board of Nursing: http://www.ksbn.org/index.htm
National Patient Safety Foundation : http://www.npsf.org/au/
Tuesday, March 4, 2008
Patient Safety Awareness Part 2
“ I knew the baby had died, but it never, never even crossed my mind that Robin would die.”
But the unthinkable happened to Glenda Rodger’s 26 year old daughter and her nearly full term fetus in July of 2006, after Robin received the wrong bag of nutrition—a bag filled with fluid the consistency of gravy meant to go directly into her stomach, was pumped into her veins instead.
No criminal charges were filed, Glenda Rodgers says it WAS a mistake, but she believes nurse Susan Meeker deserved more than an 8 month suspension and 14 hours of continuing education. The terms of the suspension were agreed upon in an order between Meeker and the Kansas State Board of Nursing, an 11 member board comprised of 9 nursing professionals and two public members.
“I would agree this is a tragic case. But we’ve seen it happen before. In 18 years, you know I hate to say I’ve seen it happen before, but it HAS. Medicine and nursing are not exact sciences. And while we don’t like errors to occur, errors are going to occur because there’s that human factor in there.”
Nursing practice specialist Diane Glynn says the Supreme Court has made it clear concerning regulatory boards: they cannot impose criminal punishment. Glynn says the board’s primary purpose it to protect the public.
“We protect them from incompetence and unscrupulous people. So we have to look at the acts that occur, total personnel history, we have to look at how long someone’s been licensed; do they have a trend or a pattern of making the same kinds of mistakes, and factor all of those things in when we come up with some kind of discipline remedy.”
Of the cases forwarded to the AG’s office in 2006, 17 resulted in outright revocation; less than 10 percent of the total. Nearly all were revoked for theft of money and or drugs or drug use—criminal acts. Mary Blubaugh is the board’s executive director
“Now, we DO have some permanent bars for some felonies against persons and those things that we don’t have to license anybody if they have those, if they are convicted of one of those, we can take their license and they won’t get it back, but that is the ONLY absolute bar that we have.”
Nurse specialist Diane Glynn says if a nurse shows he or she has completed the proper educational and treatment, the board cannot continually deny a license. However, the board can and DOES keep closer tabs on them:
“That doesn’t mean we would just hand them a license carte blanche and say ‘here…go back. Usually, we put somebody under suspension with a stay or some type of probation so that we can monitor them and make sure employers are, you know, overseeing their practice too since they are going back into the work setting.”
Wednesday, March 5, 2008
Patient Safety Awareness Part 3
In conjunction with National Patient Safety Awareness Week, experts in the fields of medicine, nursing and pharmacy are urging YOU as the PATIENT, to get more involved in your care. In the last of our reports: how the industry is trying to get you to step up and become more involved in your care.
As many as one and a half million people are injured every year by medication errors according to a recent study by the Institute of Medicine and the National Academies, To alleviate that, the study calls for ALL prescriptions to be written electronically by 2010..a good start says Scott Micek, the clinical pharmacist at Barnes Jewish Hospital in St. Louis:
“The technology is there. Certainly it’s a capital investment. But there are a number of instances and study that show that by taking handwriting out of the equation, and having it electronic as you say, certainly improves safety from that aspect.”
The other major improvement Micek and other practitioners are pushing are for is for all medications to have the proper indications marked on them..for instance, ”this medicine is for the treatment for high blood pressure.”
Better Packaging and labeling is one part of the solution, in a separate study, the Institute of Medicine calls for improvements in nursing staff levels and the work environment. And for the roughly 50 thousand licensed nurses in Kansas Nurse specialist Diane Glynn says there is a strict peer review process already in place:
Hospitals can be intimidating places. Patients are bombarded from several different sources, nurses, doctors, and nutritionists. But if its medication administered in the hospital, there is another source patients ought to consult: people like Scott Micek, a hospital-employed pharmacist.
“We are part of that white coat brigade of physicians, nurses, pharmacists, respitory therapists. You know, that mass of health care humanity that comes in to take care of you. We are part of that team. And certainly when we’re not seeking you out, if you have questions about some medication, not only seek out the doctor and nurse, but the pharmacists…”
One more check and balance that could prevent a fatal error.
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