In November 2016, a woman suffering from confusion and kidney failure was accidentally administered 25 times the usual does of a blood thinner. The woman died the next morning from internal bleeding.
An investigation into the incident by the California Department of Health revealed the dialysis patient was admitted to the hospital with blood clots in her arm and the hospital was attempting to rid the blood clots with the drug heparin. A nurse premixed a bag of heparin and saline with 25,000 units of heparin in 250 milliliters of saline, thinking the physician would administer a portion of it. However, the physician gave the patient the entire bag.
The woman was transferred to the intensive care unit immediately, but efforts to revive her failed.
The state penalized Memorial Medical Center for not following policies and protocols while administering medications.
Memorial Medical Center officials told The Modesto Bee that the hospital reported the incident to the state health department and submitted a plan of correction to prevent future mistakes.
“We are committed to the safety of all of our patients and to continuous process improvement,” a hospital statement read, according to The Modesto Bee.
More articles on healthcare quality:
36% of hospital readmissions likely do not reflect poor surgical quality
Full-time Banner Health nurse takes second in Boston Marathon: 6 things to know
Texas hospital staff find fetus in dirty linen cart
Becker’s 3rd Annual Fall Chief Pharmacy Officer Summit is the top tier event that the people leading the future of pharmacy convene. This 3-day event is built specifically for Chief Pharmacy Officers and senior pharmacy leaders. The sessions examine the workforce, financial and clinical priorities shaping pharmacy today. Becker’s is where candid discussions flourish and new ideas thrive. Becker's 3rd Annual Fall Chief Pharmacy Officer Summit
