In a recent blog post we discussed communication handoffs and gave an extreme example of how everything can go wrong.  Another dangerous and potentially costly area of concern is medication errors.  Here’s a scenario that illustrates how they can happen in a correctional healthcare setting and some potential solutions.

Inmate Smith was a 32-year-old male incarcerated for a two-year sentence for manslaughter DUI. He had a 15-year history of heavy alcohol and chewing tobacco use and was diagnosed with throat cancer 6 months in to his incarceration.  He had a growing mass causing difficulty in swallowing and pain management.  The staff moved inmate Smith to a regional infirmary ten days prior to the incident to help improve the impact of his treatment plan.

During routine shift changes, it is common procedure to do a count for all pain management narcotics between the in-coming and out-going staff.  During one of the shift changes it was discovered that inmate Smith had been administered 150mg of Oxycodone instead of the prescribed 20mg.  The nursing staff was able to assess inmate Smith and administer drugs to counteract the overdose of Oxycodone and revive him with no permanent consequences.  The medication error was immediately reported and the Health Services Administrator conducted an investigation of the circumstances.  There were basically four things that contributed to the error.

  1. The physician order gave the tablet dosage and said they could use liquid but gave no conversion instructions for the liquid.
  2. The liquid from the pharmacy was a 20:1 concentration but had no alert on the bottle.
  3. The Medication Administration Record (MAR) for the shift prior to the error referenced 7.5mg every 8 hours but did not give the conversion for the concentration.
  4. The nurse that made the error relied on the MAR and did not note the concentration level.

Medication errors are best avoided by having high quality systems in place and a “Just Culture,” where frontline care providers are comfortable disclosing errors, including their own, while maintaining professional accountability.  If you search on Google you can find a lot of information about Just Culture and find tips about how to implement it in your organization.  Michelle Foster Earle discussed Just Culture in depth as part of a correctional healthcare webinar she presented on medication errors referenced in the link below.  Also in the webinar, Catherine Knox, RN, and Lorry Schonley, PhD analyze this case and detail the elements of a good medication delivery system.

Poor communications is a big issue in patient care situations. As for the case of inmate Smith, he sued the correctional facility but because the staff reacted quickly and informed their insurance company right away, the case had a good outcome, unlike our handoff case (outlined in my previous blog post). The inmate settled for $50,000.

Link to the correctional healthcare webinar:

In our next post we will discuss good claims management and the elements that drive better outcomes.