Lehigh Valley Hospital-Cedar Crest in Allentown, Pa., has come under fire after the Pennsylvania Department of Health published a report showing clinicians at the hospital used malfunctioning blood sugar testing strips that led to a fatal medication error, according to a Morning Call news report.
A patient who had undergone a kidney transplant was being monitored by physicians and nurses. Although the patient had extremely low blood sugar levels, clinicians used a blood sugar testing strip that incorrectly showed the patient had high blood sugar levels and proceeded to administer insulin to the patient as treatment.
Some time later, the patient underwent another bedside testing strip as well as lab testing. The bedside test again showed high levels of blood sugar, while the lab results showed depressed blood sugar levels. The attending physician was not alerted of the test discrepancy and improperly administered more insulin to the patient.
According to the news report, a nurse monitoring the patient from a remote site failed to notify attending physicians that she knew about the malfunctioning bedside tests. What's more, the physician who received the correct lab results indicating low blood sugar levels failed to notify the attending physician about the data discrepancy.
As a result, the patient remained on an insulin drip for 10 hours and received an additional insulin injection on the supposition his blood sugar levels were high. That patient later died of complications including swelling of the brain and respiratory failure.
LVH issued a statement in which it expressed sadness and also reported changes to improve its processes and procedures. The statement also said the patient's family had hired a lawyer and therefore could not make any further comments, according to the news report.
Read the news report about the medication error at Lehigh Valley Hospital-Cedar Crest.
Related Articles on Medication Errors:
Journal Article Outlines "Principles of Conservative Prescribing"
Study: E-Prescribing Systems Should Not Be Used to Identify Error-Prone Physicians
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A patient who had undergone a kidney transplant was being monitored by physicians and nurses. Although the patient had extremely low blood sugar levels, clinicians used a blood sugar testing strip that incorrectly showed the patient had high blood sugar levels and proceeded to administer insulin to the patient as treatment.
Some time later, the patient underwent another bedside testing strip as well as lab testing. The bedside test again showed high levels of blood sugar, while the lab results showed depressed blood sugar levels. The attending physician was not alerted of the test discrepancy and improperly administered more insulin to the patient.
According to the news report, a nurse monitoring the patient from a remote site failed to notify attending physicians that she knew about the malfunctioning bedside tests. What's more, the physician who received the correct lab results indicating low blood sugar levels failed to notify the attending physician about the data discrepancy.
As a result, the patient remained on an insulin drip for 10 hours and received an additional insulin injection on the supposition his blood sugar levels were high. That patient later died of complications including swelling of the brain and respiratory failure.
LVH issued a statement in which it expressed sadness and also reported changes to improve its processes and procedures. The statement also said the patient's family had hired a lawyer and therefore could not make any further comments, according to the news report.
Read the news report about the medication error at Lehigh Valley Hospital-Cedar Crest.
Related Articles on Medication Errors:
Journal Article Outlines "Principles of Conservative Prescribing"
Study: E-Prescribing Systems Should Not Be Used to Identify Error-Prone Physicians
Study: Medication Burden, Patient Age Risk Factors for Adverse Drug Events