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Medication errors and second victims -- making things right

Medication errors in Ohio are potentially devastating. An Ohio pharmacist once served six months in jail for neglecting to detect a mistake made by a technician in mixing chemotherapy. A 2-year-old girl, receiving what was to be her last chemotherapy treatment, died as a result of the medication error in giving the girl an overdose of saline. Perhaps to cut costs, the pharmacist was working alone on the Sunday he made the mistake; with no help other than the technician who composed the fatal mixture. The fact that the pharmacist and others who have committed similar forms of medical malpractice have felt overwhelming pangs of guilt has lead to the coining of a descriptive phrase for them, the "second victim."

A second victim is loosely defined as a caregiver who is traumatized as a result of an unexpected patient death or injury. When the death or injury was caused by the negligence of the caregiver, the grief felt by the caregiver sometimes leads to tragic outcomes. Last April, a nurse in Washington committed suicide seven months after giving an infant a fatal overmedication dose of calcium chloride. The 8-month-old baby died, and the nurse was fired after a 20-year unblemished work history. In 2006, a Wisconsin nurse pleaded guilty to two misdemeanors after she killed a patient by incorrectly giving her the contents of an epidural bag intravenously.

Some observers argue that hospital and medication errors are dealt with by a whack-a-mole mentality. By that they mean that, instead of addressing the nature of the system that lead to the error, hospital administrators and others simply whack the error on its head when it crops up, hoping to never see it again. Others say the system should be less about punishment and more about collaborating to create as failsafe a system as possible.

And therein lies the rub. No system, even a technologically based one, is perfect. Mistakes happen, and when medical mistakes happen, people suffer -- even die. Clearly the medical profession should do all within its power to reduce medical error, but by the same token those Ohio residents that suffer from the mistakes have every right to expect full accountability for the damages they suffer.

Source: The Pharmacy Practice News, "The 'Second Victims' Of Medication Errors Begin To Gain Support," Karen Blum, Nov. 16, 2011

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