Prosecutor seeks jail time for nurses that poisoned infants

It's sad but they nurses should have looked a the bottles. and WHO is stupid enough to put cleaning solutions close to the meds...........under the sink or something.

Any time you have a major error like this you MUST look at the system under which you have asked your staff to function. And without fail, when you do this, you find a chain of errors that lead up to the last big error. Medication errors do not happen in a vacuum.

It is imperative that people who make medications assure that packaging is clear, readable and the information you most need (name of the medication, strength etc) be written in large letters and in bright colors. Second, you MUST assure that medications are not packaged like non medicine. You cannot imagine how some medications arrived. I see medications packaged every day where the writing is so small, that even with my glasses, I cannot read the expiration dates. The lettering is so small that I see nurses who don't usually wear glasses having to wear them just to read the label.

When you are a nurse working in a fast paced environment, you sometimes run on instinct. Your training kicks in, and like driving a car, you learn to read the road and depend on certain indicators to know that what you are doing is correct. And one of these things in the identification of the tools around you that you use every day. Remember that nurses are the end users in the system. And they depend on the people up the chain to do what they are supposed to do so that we, the end user, can administer medications and perform other tasks in a safe manner. And yes, as nurses we are to read labels before we give a medication but I can tell you from experience that human nature being what it is, you identify some medications by the bottle they are in. And when this bottle looked like the one next to it, it was chosen at random and poured.

So if the pharmacy sends me a bag of medication with a label on it that says it has X then all I can do is assume that X is what is there. I have no way at the bedside to test that bag or bottle of medication to assure that what the pharmacy did was correct. If the pharmacist has added the wrong medication or the pharmacy tech has doubled the dose, I have no way to know that. But I guarantee you that when I administer that medication, and something bad happens, it will be by butt in the court.

It is imperative that medications not be stored with non-medications. This is an example of how labeling and storage policies went wrong. And I blame the powers that be for that. Because the folks up the food chain are responsible for putting systems in place to assure that errors like this do not occur. Because in spite of what one might think, no nurse is out to kill a patient.