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Another infant death from medication error.


Nebraska Med. Center Investigates Staff After Girl’s Death

Staff Overdosed Almariah Duque On Blood-Thinning Drug

Oh no.  Another death from a medication error.  How tragic for the family.  In an updated story on 4/3/10 some staff have been suspended.  
Some quick observations:
  • By the tone of the headline and staff suspension it looks like the sharks are in the water.
  • Will Just Culture principals prevail or are scape goats being lined up for slaughter?
  • My fear is it is the later.
  • According to a previous press release the hospital did have Bar Code Medication Administration (BCMA).  Technology is not the solution to decrease medication errors.  It is a lot more complicated than that and has been address in this blog many times.
  • While I tweeted “Time for another pharmacist to go to jail”, that seems harsh.  It comes off the offensive journal article and complete lack of action by a pharmacist professional society (ASHP) on the jailing of a pharmacist for a medication error that was clearly a system error and not an intentional error, resulting in a infants death.  Search this blog for “Eric Cropp” or see
  • I pray for the family and that Just Culture will prevail.


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