Recently, the Institute for Safe Medication Practices (ISMP) issued a report asking that Maryland pharmacists, as well as pharmacists across the country, take additional precautions in the wake of a fatal 2017 pharmacy error. The ISMP is a nonprofit organization dedicated to reducing the number of pharmacy errors across the United States. In furtherance of that goal, the ISMP operates a voluntary error-reporting system. The ISMP then uses this data to work with pharmaceutical companies to eliminate the root causes of common errors such as similarly named drugs, confusing packaging, and dangerous device design.
According to the ISMP report, a patient was admitted into the ICU with a headache and vision loss. An MRI was conducted, and it was determined that the patient had a hematoma of the brain. The patient was transferred, and a full-body scan was ordered. While the radiologist was explaining the procedure to the patient, the patient indicated she had claustrophobia. The radiologist requested the patient be given a dose of Versed to help with her claustrophobia.
Evidently, the patient’s primary nurse requested that a radiology nurse provide the patient with the medication. The radiology nurse declined, stating that the patient would need to be monitored after administration of the drug. The primary nurse indicated she would send another nurse to the radiology department to monitor the patient after she was given the medication.