IDAHO— A nurse at St. Luke Magic Valley Medical Center is facing a wrongful death suit filed by the family of a seven-month-old child who received an adult dose of saline mixed with potassium phosphate.
The nurse involved in the suit is Jeffrey Smith, a travel nurse.
“(Smith) chose not to check the label on the bag of saline before administering the drug to August,” According to the lawsuit. “Had he checked the label as required, he would have discovered that the saline contained potassium — which is lethal to infants such as August.”
After the child's death multiple investigations about the hospital's safety and medication administration protocols were examined. The hospital has improved training for nurses who are agency, travel or PRN, and more training in medication checking has been implemented.
The family has not filed suit against St. Luke’s
The Twin Fall's Prosecutor decided not to charged Nurse Smith with any criminal wrongdoing in January. Even though the nurse was ultimately responsible for the child's death and had he checked the medication prior to administration then he would have prevented the death. The Prosecutor concluded that the nurse's actions did not represent criminal negligence.
“We don’t disagree with the prosecutor’s decision not to prosecute,” Jarom Whitehead, an attorney representing the family, said at the time.
Travel nurses are utilized to fill in for positions short term and are often not familiar with hospital protocols.
Michelle Bartlome, hospital spokeswoman said “Travel nurses come to us properly certified, licensed and screened before starting work,” “They have to complete a facility and organizational orientation and are trained by another registered nurse before we consider travel nurses ready to treat patients.”
The family's attorney Mr. Whitehead said, “This family’s been devastated by this. “August was a beautiful, happy, engaging child, and it’s a tremendous loss as you can understand. We will do everything we can do to understand how this happened and ensure it doesn’t happen again.”
On the night August died he had been experiencing cardiac arrhythmia and his parents brought him to the emergency room for treatment. A doctor ordered heart medication and saline solution as treatment for the infant's arrhythmia.
“A short time later, while in his father’s arms, the baby began arching his back and his eyes rolled back in his head,” According to the attorneys for the Elliot family “He was struggling and his muscles became rigid.”
Another nurse checked the medication that had been given to the child and noticed that it was an adult dose of potassium. Enough to quickly stop the heart of a child that age.
While I am usually the nurse's advocate whenever possible I have to say that this case bothered me. Although the nurse was a travel nurse and even if he wasn't trained properly at that facility, it doesn't explain why a nurse who should know the five rights of medication administration would make this type of error.
I realize "to err is human," but this is unacceptable. This is basic nursing 101 and should not require any further teaching by the facility.
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