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Name:
Location: Allentown, PA

I'm a Christian wife and a mom to three daughters and two sons. I'm a member of the board of directors of EmPoWeReD Birth. In my "spare time" I'm a doula, and a certified childbirth instructor.

Thursday, July 27, 2006

16 Year Old Killed in Childbirth by Medical Error

Recently 16 year old Jasmine Gant in Madison Wisconsin was killed when a medical error occured. What happened? She was pregnant, and went to the hospital to birth her baby. Apparently she was Group B Strep positive, so was prescribed IV antibiotics. However, instead of hooking up a bag of antibiotics to her IV drip, a bag of epidural medications were hooked up. The antibiotics would typically be run in over the course of about 30 minutes, I would guess that the same sized bag of epidural medication would be expected to be run in over a time period of several hours. The mother started seizing, and eventually died--my guess would be that she died before the mistake in medication was even discovered, so while resucitation efforts were underway, she was probably continuing to receive the medication.

To read the media accounts, it really seems like the nurse who attached the medications is being hung out to dry. And she certainly does bear a large part of the responsibility. She should have visually confirmed that the label on the IV bag was for the correct medication. Further, it appears that there is a systemic problem in that particular hospital were the barcoding system that is in place to prevent such medication errors is not actually used by the nursing staff.

However, there is a HUGE key question that is not getting asked. Because the medications used in epidurals are controlled narcotics, they are generally kept under lock and key. As a doula who has worked in several hospital, I've never seen them accessible to the nurses, but rather kept in a cart that the anesthesiologist has the key to. Several other doulas have raised the same concern in the doula community. The anesthesiologist mixes up the medication cocktail on a "per customer" basis--it is not premixed and placed in IV bags. So why in the world was the nurse in this case even able to have access to a bag of IV fluid with epidural medications in it? Where is the anesthesiologist in this picture?

Bottom line folks...don't let something get injected into you (or your loved one) or hooked up to your IV unless you personally inspect the label.

4 Comments:

Blogger I am a Milliner's Dream, a woman of many "hats"... said...

Hi! Just found you via a Technorati search using "doula" as they keyword!

Hh

10:25 AM, July 28, 2006  
Blogger Lucina said...

This it too funny. I just clicked on Milliner's Dream's search chart, looked at the same list of search results, and this was the first article I chose to read!

Just wanted to add a datapoint - in the large teaching hospitals I work in (in Toronto) the epidural meds are in fact mixed up in advance and frequently brought into the room by the nurse. I don't know where they're getting them from, but when an epi bag (or syringe - I see a variety of different delivery systems) runs out, the nurse replaces it without calling in an anaesthetist.

Too bad this young woman didn't have a nosey doula reading the label on the bags. I know I always do that.

12:28 PM, July 28, 2006  
Blogger Jenn said...

Milliner's Dream--I've been on your blog before, thank you for visiting mine!

Lucina--interesting about how nurses handle the meds in your area. To be honest, I've never had a client have an epidural long enough to need a replacement bag of meds...the common thread I was seeing in other American doulas though was that the meds are kept under lock & key as I've observed. ANYWAY...I'm like you--a doula who checks and writes down the meds her clients are given (I can't get the specifics on epidurals or some cesarean meds), writing down specific dosing information so that my clients can have those records after the fact.

5:34 PM, July 28, 2006  
Anonymous cjmr said...

At the hospital I delivered both my children in, the epidural/spinal meds came in on a cart pushed by the anesthesiologist, and he took it with him when he left. Neither time was I on it long enough to need a second bag, so I don't know how they would have handled that.

7:00 AM, August 02, 2006  

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