Friday, 11 May 2012

Medication Safety Awareness Month!

I feel this needs to be  blogged to get it off my chest and also be made aware of that this practise does happen and I strongly feel the urgency to have it eliminated.

Medicine administration is a basic nursing skill and is taught in the early years of training.  To read a drug chart is not difficult, so I have been told (I wish it was).  So, why are there so many errors???????

Here are a few mishaps that have happened and continue to do so to us here at RCH:

* Medicine given 2 hours early, (I was sleeping) - "I read the 8am as 6am, that will teach me for trying to read in half light".
* Anti nausea - continually given late, up to an hour.  Causing Allegra to vomit.
* Medicine bought in 2 hours early - "I read the drug chart as 11am instead of 1pm."
* Anti nausea/sedation - dosage is 2ml, 2.2ml drawn up.  This is 10% more.
* I asked for Allegra's 7pm medicines, her regular MS Contin did not come but a break through Oxycodone came.  I stopped it before it went in, just in time.
* Doctors leaving medicines off or the prescribed route left off the drug chart when a new chart is written.  This then means nurses not aware of the medicine, I have a sick/miserable baby who could be in pain and I don't know why.  I eventually work it out that Allegra has not been given her medicine because the doctor just didn't write it up.
* Medicine given down Allegra's nasal gastric tube instead of mixed in her feed - causing Allegra to wake up dry-wrenching, gagging then vomiting, "I didn't read the drug chart".
* Medicine given 3 hours late - causing Allegra to be very unsettled and miserable, "I forgot to give Allegra her Panadol".
* Pre-meds written up with incorrect times - causing Allegra to be not sedated on time or procedure needs to be delayed.
* Medicine drawn up 3.75ml and about to be given, it should be .375ml - "it has been double checked by another nurse", I continue to question, doctor checks it, "Oh Allegra would have been pooing all night". 10 times the required dosage.
* Medicines not signed off on.
* Syringes not taken out of pump when drug is ceased - causing new Nurse to come in and turn it on.  This medicine has been sitting in the machine for 12+ hours.
* Was told Chemotherapy will run for 1 hour when I knew it ran for 6hours.  She believed this until I told her to check the protocol before putting it up.
* Given incorrect medicine as a  pre -med to medicine that Allegra is not even on.  Work that one out!!!

April was Medication Safety Awareness Month.  I found this notice stuck up in the kitchen and found it ludicrous.  It was the 6th of April and I counted  5 "human errors".  Maybe it was to start mid month........

I find this unacceptable, neglectful and damn right outrageous. 9/10 is just good not enough when it comes to administering medicines.
I have had numerous discussions with various people (Consumer Liaison Officer, Unit Manager, Clinical Psychologist,  Head of Department - Oncology) to sort this out and to prevent it from happening again to Allegra or any other totally dependant innocent child.  Unfortunately, to date it has not completely been sorted out and there are minimal improvements.  I am horrified, frustrated, tired and am absolutely mortified that these practises happen daily to goodness knows how many kiddies.
What will it take?
When I was at home nursing my little Allegra the correct medicine with the correct dosage was given at the correct time the correct way.  I have not been trained and it is not my profession and I am human and there were no errors made.

All I can say is I am Allegra's advocate. I always will be and I will not stop doing what I am doing and it is lucky I am here taking care of her.
I check all of Allegra's medicines and I try and be here all the time to prevent errors, unfortunately I do sleep.
It has come to the conclusion and realisation that no medicine is to be given to Allegra.  The nurses can draw them up and bring them into our room.  I will check the medicine with the nurse, then the dosage and I will administer it to Allegra.
At least this way I can be assured that Allegra is medicated correctly in the best hands.


  1. Such a disgrace and so unacceptable that you need to check and double check the medications. Thankfully you are so diligent and observant with everything, and a champion for Allegra and her needs. Dont ever doubt your special perception on things, it has always proved to be correct. Once again I say you are all amazing Jacqui. I hope you can get some resolution from the hospital on some of their mismanagement, so that you can rest a bit easier. Love DuDu

  2. Hi Jacqui, As an ex-nurse I can only think that there is something really wrong with the system that they are using for medication. It is amazing that there are so many errors - getting doses that wrong is just terrible. I feel so sorry that this another thing you have to worry about. Thinking of you both. Love Ally & John

  3. OMG!!! Jacqui, you've got to email the link for this post to John Faine at ABC 774. He specializes in taking these sort of issues up, to right these sort of horrible wrongs perpetrated on innocent people by big public institutions. The Hospital may deal with it their way but may just pay you lip service and protect their reputation (and backsides).

    I read your entire blog from start to finish, with tears in my eyes. But after reading this post just felt so angry - Allegra and you just don't deserve this extra stress! You are such a beautiful mum, little Allegra couldn't have chosen a better one.

    Darcy sends big hugs to Allegra and extras from me and Mich to you both. Xxx

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