A Tired Nurse’s Fatal Medication Error

Jasmine Gant was a teenager, about to give birth in a Milwaukee hospital’s Labor and Delivery unit during the July 4 holiday. Her nurse had worked at the hospital for 13 years, receiving good performance reviews. The nurse worked two eight-hour shifts back to back the night before, ending at midnight, and then slept at the hospital for a few hours before starting work at 7 am.

She took several medications from a storage area, including an epidural, though the doctor had not yet ordered it. She placed the medications on a counter, where another nurse placed a bag of penicillin ordered from the pharmacy. Both medications were in clear plastic mini-bags, with the name of the drug printed on each bag. The epidural medication also had a bright pink label. The nurse spiked the bag she thought contained penicillin into an IV line into Jasmine's arm. However, it was the epidural medication, which is to be administered into the spine, not intravenously. Jasmine had a seizure—a severe adverse reaction. The nurse pulled the medication tube out of the IV and a Code Blue was called. Efforts to revise Jasmine failed, and an emergency cesarean section delivered the baby, who survived.

Type of Errror: Wrong drug, and wrong route

Lesson for Patients & Advocates: Check the label yourself before allowing anyone to give you medicine.

We’ll revisit this later this week. Or you can read more now from the newspaper story or at the AtYourCervix blog posting of Nov. 25.

Readers: Do you have a story to tell?