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A Montana nurse admitted to a coroner’s inquest that she adminstered a wrong medication to a patient who died shortly after receiving the drug. The patient came to trhe emergency room of the hospital with difficulty breathing. The doctor ordered lasix, a diuretic, to help draw out fluid that may have been contributing the respiratory problems.

Instead of taking the lasix from the pharmacy, she took potassium from the shelf below and gave it to the patient. The patient died shortly thereafter from cardiac dysrythmia due to potassium toxicity.

There are two elements to the cause of this patient’s death: one is a simple nursing error, the other is a human factors issue.

Nurses are trained to check the “5 R’s” before giving medication to a patient: right patient, right drug, right time, right dose, and right means. In this case, the drug was not the right drug, and there was a fatal result.

The human factors aspect of the case reltes to how the medication was stored at the hospital. At the inquest, it came out that the potassium and the lasix were both stored in a cabinet at below waist level, which made it more difficult for the nursing staff to make sure that they were getting the right medication out of the pharmacy.

To their credit, both the nurse and the hospital admitted the error instead of trying to cover it up, and the hospital is taking steps to prevent a recurrence.

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