Improperly Maintained Equipment Caused Overdose
When a 29-year-old mother of three died from an accidental overdose of a chemotherapy drug, the hospital admitted the error and issued a public apology. That didn’t stop the family from threatening a lawsuit.
The hospital immediately began an investigation to discover what exactly had happened by talking to all witnesses who looked at the mother’s charts, interviewing other staff members who reviewed them and finally consulting an external review organization.
The external review came back with questions about the infusion equipment's maintenance and updates. The hospital found that the infusion pump had a history of overmedicating problems and that the manufacturer had offered to fix faulty pumps at its own expense. Yet this did not appear in the hospital’s documentation for this piece of equipment. The independent review determined that the hospital had not kept the pump current.
Although no individual was cited for the mother’s death, the family followed through with its lawsuit against the hospital based on its lack of maintenance and failure to update the pump.
A hospital’s operating infrastructure, equipment maintenance, and systems are often at the root of sentinel events. External Peer Review can help or objectively indentify these issues, leading to corrective action.