According to news reports concerning this incident, a transcription error is likely to blame for the patient receiving 80-milliequivalent doses of potassium over an eight day period while she was a patient at Bethany Home of Alexandria. A state investigation determined that the improper potassium dose was to blame for her cardiac arrest.
Making this tragedy even more concerning is the fact that the exceedingly high dose was recognized by a pharmacist who was filling the woman’s prescription who brought the unusually high dose to the attention of staff at the facility— only to be discounted.
After taking the toxic dose of potassium for eight days, the patient was taken to a nearby hospital for complaints related to chest pain and shortness of breath. Medical personnel at the hospital attempted to treat her for cardiac arrest and administered medications to bring down her potassium levels, but the woman died within a week of her hospitalization.
Following a comprehensive investigation of this incident, the Minnesota Health Department released a report that places blame squarely on the shoulders of the facility, Bethany Home of Alexandria, saying that “a serious medication error of this proportion indicates a widespread systemic problem.”
As a lawyer who has represented people in cases involving medication errors, I continually am frustrated by the fact that many nursing home employee blindly administer medications without clarifying that the medication is indeed correct or the dose is accurate. Given that nursing home employees have familiarity with most of the medications administered, I find it reprehensible when employees knowingly administer potentially dangerous dosages to patients when they know better.
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