Chapter 7
For the next thirty minutes Mark checked all the pharmacy slips from the second floor trying to see if he could find the one for the Penicillin that had been sent up for Steve. When he finally found it he was puzzled by what he saw. Steve's name was on the slip and the room number did say 214 but the request was definitely for the antibiotic that nearly killed his son. What Mark couldn't figure out was how someone could have made such a mistake.
Mark sat and stared at the slip for several minutes when suddenly an idea came to him. He pulled up the pharmacy slips for the third floor and searched for room 314. It all started to make sense to him now. In room 314 was a patient named Steve M. Kellie who was on Penicillin. The next question was who had managed to get the two patients so completely mixed up? And why had the chart been changed instead of the discrepancy in the order being investigated. These were questions that Mark intended to find the answers to as soon as he could explore it further.
Mark headed back up to his son's room and sat with him for the remainder of the baseball game. The two men argued with each other over who was the better ball player, thoroughly enjoying each other's company and the game. By the time the last inning was over Steve had become rather quiet and Mark noticed that he was having trouble keeping his eyes open.
"I think it's time someone went to sleep. You've had a pretty rough day." Mark reached for the controls and lowered the head of his son's bed and started settling him in for the night.
Steve started to protest that he wasn't sleepy at all but a large head splitting yawn got in the way, which caused him to wince a little in pain. Mark smiled down as he watched Steve drift off. He sat for about an hour just watching and making sure that his son was resting peacefully with out any side effects from the close call earlier.
Once he was sure that Steve would not wake up, Mark made his way to the nurses' desk and sat down reading a patient's records so that he didn't look as if he was observing the activities and actions of the staff.
Everything seemed to be going along routinely when suddenly he heard one of the nurses swear under her breath. He looked up and watched over his glasses as she threw the file down that she was looking at. Turning to one of the other nurses, the agitated woman started to complain about the inefficiency of the hospital.
Mark chose to sit quietly and just observe the nurse's actions for a while and see if she could shed any light on what might have happened to his son's chart. Sure enough she began complaining about the fact that she had just corrected the perscription the night before and now someone had come along and messed it up again.
Mark continued to watch as the nurse pulled out the medication sheet and a new request form. Not once did she bother to look at the chart as she filled in the new forms. She continued to grumbled about having to correct things again and how much time she was wasting by having to alter the same information night after night.
When she finished filling out the slip for the medication Mark walked up to her and very politely asked to see the paper before she sent it to the pharmacy. The nurse was a little startled by the request but reluctantly handed the form over to Mark. Sure enough the form said room 214 and the order was for Penicillin.
"Excuse me. What floor were you working before you started on this floor?" Mark asked the nurse.
"I worked third floor for two weeks. Before that I was assigned to pediatrics for a month. I've been all over this hospital in the last three months." She answered.
"How long have you been on this floor?" Mark asked
"I don't know. Maybe two or three days I guess. Why?" The nurse was clearly starting to get agitated.
"I see. When was the last time you had any time off?" Mark gave the nurse a look of real concern.
With tired eyes she looked up at the kindly faced doctor and said. "I really don't remember. I'm just a temp. When they need someone to fill in they call me. I've been working steady for several weeks now. I've been called everyday for over a month. I really am trying to keep up and not let my work get sloppy."
Mark looked at her with sympathy. She was so tired that she was nearly in tears. Because she was so tired, she was endangering her health and in the process of trying to keep up with the grueling pace she had endangered her patients as well.
"What agency do you work for?" Mark wanted to know.
"Jiffy Nurse. Listen please I can't afford to loose my employment. I really am trying to do a good job. If you tell them I was slacking off they won't call me anymore." She pleaded with Mark.
"I want you to look at this form and tell me what you wrote for the room number." Mark handed her the slip and watched as she read the number out loud.
"Room 214. I don't understand." She looked at Mark confused and shrugged her shoulders.
"What is the patient's name?" Mark asked her.
"Steve M. Kellie." She once again looked at Mark confused by his question.
"Are you sure?" Mark once again handed the paper to her.
She stood and looked at the slip and then at Mark for a minute clearly confused by his question. She glanced down at the slip again and then suddenly she realized her mistake.
"Oh no. What have I done?" By now she was in tears and looking very pale.
Mark was suddenly very concerned that she was about to pass out on the spot so he guided her over to a chair settling her into it and drawing up another one so that he could sit facing her.
"Yesterday my son received a dose of penicillin. He is highly allergic to this antibiotic. He went into anaphylactic shock and nearly died. We discovered that the medication ordered the night before was penicillin. Not once did anyone check the medication against the chart or the MAR. It was stashed into the drawer and left. Then when it was time for his next dose to be given the medication nurse failed to check the vial against the MAR to see if it was the correct antibiotic. As a result I nearly lost my son to errors and incompetence. When you looked at his chart didn't you notice that it was flagged?" Mark felt sorry for the nurse but what had happened was inexcusable and must be dealt with appropriately.
Mark knew if this mistake had happened to any other patient the family would surely be talking to their lawyers about a lawsuit and they would have been justified.
"I'm so sorry, Doctor Sloan. I don't know how I could have made such a terrible error. I've never made this kind of mistake before." By this time the nurse was crying.
Mark felt she wasn't entirely to blame. "I want you to go on and get some sleep. I'm afraid that there will be a review of this but now I know what happened. I plan to write up a report to explain some of what I discovered during my inquiries. But for now you need to go home. I can't allow you to work the remainder of your shift under these circumstances. I don't think you would have made this mistake if you had been allowed to take some time off and get a chance to rest.
The woman offered her apologies again and went to collect her things. Mark watched her go and made his mind up that he would have a talk with the Director of Nurses and find out why a temp had been allowed to work for over a month or better with out taking any time off for rest. After making sure that the other staff on duty would be able to cover the remainder of the shift without the extra help he went back to check on Steve.
He watched his son as he slept thinking about the many times he had stood in that very spot thankful that once again Steve had been spared to see another day. Mark also knew that he would more than likely stand there again. It wasn't easy to see his child hurt or sick but he accepted the fact that it was all part of being a cop.
Without even thinking about it, Mark moved over to the chair and settled himself in for what was left of the night. He couldn't and wouldn't leave his son alone this soon after the close call from the day before.
For the next thirty minutes Mark checked all the pharmacy slips from the second floor trying to see if he could find the one for the Penicillin that had been sent up for Steve. When he finally found it he was puzzled by what he saw. Steve's name was on the slip and the room number did say 214 but the request was definitely for the antibiotic that nearly killed his son. What Mark couldn't figure out was how someone could have made such a mistake.
Mark sat and stared at the slip for several minutes when suddenly an idea came to him. He pulled up the pharmacy slips for the third floor and searched for room 314. It all started to make sense to him now. In room 314 was a patient named Steve M. Kellie who was on Penicillin. The next question was who had managed to get the two patients so completely mixed up? And why had the chart been changed instead of the discrepancy in the order being investigated. These were questions that Mark intended to find the answers to as soon as he could explore it further.
Mark headed back up to his son's room and sat with him for the remainder of the baseball game. The two men argued with each other over who was the better ball player, thoroughly enjoying each other's company and the game. By the time the last inning was over Steve had become rather quiet and Mark noticed that he was having trouble keeping his eyes open.
"I think it's time someone went to sleep. You've had a pretty rough day." Mark reached for the controls and lowered the head of his son's bed and started settling him in for the night.
Steve started to protest that he wasn't sleepy at all but a large head splitting yawn got in the way, which caused him to wince a little in pain. Mark smiled down as he watched Steve drift off. He sat for about an hour just watching and making sure that his son was resting peacefully with out any side effects from the close call earlier.
Once he was sure that Steve would not wake up, Mark made his way to the nurses' desk and sat down reading a patient's records so that he didn't look as if he was observing the activities and actions of the staff.
Everything seemed to be going along routinely when suddenly he heard one of the nurses swear under her breath. He looked up and watched over his glasses as she threw the file down that she was looking at. Turning to one of the other nurses, the agitated woman started to complain about the inefficiency of the hospital.
Mark chose to sit quietly and just observe the nurse's actions for a while and see if she could shed any light on what might have happened to his son's chart. Sure enough she began complaining about the fact that she had just corrected the perscription the night before and now someone had come along and messed it up again.
Mark continued to watch as the nurse pulled out the medication sheet and a new request form. Not once did she bother to look at the chart as she filled in the new forms. She continued to grumbled about having to correct things again and how much time she was wasting by having to alter the same information night after night.
When she finished filling out the slip for the medication Mark walked up to her and very politely asked to see the paper before she sent it to the pharmacy. The nurse was a little startled by the request but reluctantly handed the form over to Mark. Sure enough the form said room 214 and the order was for Penicillin.
"Excuse me. What floor were you working before you started on this floor?" Mark asked the nurse.
"I worked third floor for two weeks. Before that I was assigned to pediatrics for a month. I've been all over this hospital in the last three months." She answered.
"How long have you been on this floor?" Mark asked
"I don't know. Maybe two or three days I guess. Why?" The nurse was clearly starting to get agitated.
"I see. When was the last time you had any time off?" Mark gave the nurse a look of real concern.
With tired eyes she looked up at the kindly faced doctor and said. "I really don't remember. I'm just a temp. When they need someone to fill in they call me. I've been working steady for several weeks now. I've been called everyday for over a month. I really am trying to keep up and not let my work get sloppy."
Mark looked at her with sympathy. She was so tired that she was nearly in tears. Because she was so tired, she was endangering her health and in the process of trying to keep up with the grueling pace she had endangered her patients as well.
"What agency do you work for?" Mark wanted to know.
"Jiffy Nurse. Listen please I can't afford to loose my employment. I really am trying to do a good job. If you tell them I was slacking off they won't call me anymore." She pleaded with Mark.
"I want you to look at this form and tell me what you wrote for the room number." Mark handed her the slip and watched as she read the number out loud.
"Room 214. I don't understand." She looked at Mark confused and shrugged her shoulders.
"What is the patient's name?" Mark asked her.
"Steve M. Kellie." She once again looked at Mark confused by his question.
"Are you sure?" Mark once again handed the paper to her.
She stood and looked at the slip and then at Mark for a minute clearly confused by his question. She glanced down at the slip again and then suddenly she realized her mistake.
"Oh no. What have I done?" By now she was in tears and looking very pale.
Mark was suddenly very concerned that she was about to pass out on the spot so he guided her over to a chair settling her into it and drawing up another one so that he could sit facing her.
"Yesterday my son received a dose of penicillin. He is highly allergic to this antibiotic. He went into anaphylactic shock and nearly died. We discovered that the medication ordered the night before was penicillin. Not once did anyone check the medication against the chart or the MAR. It was stashed into the drawer and left. Then when it was time for his next dose to be given the medication nurse failed to check the vial against the MAR to see if it was the correct antibiotic. As a result I nearly lost my son to errors and incompetence. When you looked at his chart didn't you notice that it was flagged?" Mark felt sorry for the nurse but what had happened was inexcusable and must be dealt with appropriately.
Mark knew if this mistake had happened to any other patient the family would surely be talking to their lawyers about a lawsuit and they would have been justified.
"I'm so sorry, Doctor Sloan. I don't know how I could have made such a terrible error. I've never made this kind of mistake before." By this time the nurse was crying.
Mark felt she wasn't entirely to blame. "I want you to go on and get some sleep. I'm afraid that there will be a review of this but now I know what happened. I plan to write up a report to explain some of what I discovered during my inquiries. But for now you need to go home. I can't allow you to work the remainder of your shift under these circumstances. I don't think you would have made this mistake if you had been allowed to take some time off and get a chance to rest.
The woman offered her apologies again and went to collect her things. Mark watched her go and made his mind up that he would have a talk with the Director of Nurses and find out why a temp had been allowed to work for over a month or better with out taking any time off for rest. After making sure that the other staff on duty would be able to cover the remainder of the shift without the extra help he went back to check on Steve.
He watched his son as he slept thinking about the many times he had stood in that very spot thankful that once again Steve had been spared to see another day. Mark also knew that he would more than likely stand there again. It wasn't easy to see his child hurt or sick but he accepted the fact that it was all part of being a cop.
Without even thinking about it, Mark moved over to the chair and settled himself in for what was left of the night. He couldn't and wouldn't leave his son alone this soon after the close call from the day before.