I hate this. A patient with cancer died after being fitted with a pump that injected all her chemotherapy medicine in four hours instead of four days. Two nurses checked the programming of the pump but they both misinterpreted the physician’s prescription. The woman returned to the hospital but was sent home and told to come back if she felt sick. She later returned to the hospital, was admitted, and died.
The hospital says that they feels terrible and they’re very sorry and they want to reassure everyone that chemotherapy is really very safe and that everyone should trust their medical staff.
That’s not what I want to hear in an apology. I want to hear what they’re going to do to make sure that it never happens again. How about training the nurses on the programming the pumps? Educating them about the standard dosages of chemo? Teaching the doctor to print?
I was hooked up to an antibiotic pump for a couple of weeks, and one of the home nurses who re-charged it was clearly flustered by the device. She ended up programming it to deliver four doses when it would hold only three: so that it started to pump air into my veins! Did she receive training to operate the device? Why did she think a device with a 24-hour cycle could be programmed to for more than 32 until the next refill? So I think that training, re-training, and reviewing would not go amiss.
And how about that “go home and call us when you get sick” advice? How about, “Oh, my God, you’ve had too much of that stuff, let’s try to get a little of it out of you!” instead? Is there a procedure for overdoses? Chelating, blood transfusions, glucose drip, drinking lots of water, symptom reduction? There has to be something better than, “Oops, sorry about that… better luck next time.?
