Haunted By Inaction
By Val Jones, MD
When I was a medical student rotating at a hospital that shall remain unnamed, I witnessed a medical error that has haunted me ever since. I was partnered with a team of residents in the inpatient pediatric unit, and late one night a two month old baby was accidentally infused with an entire bottle of Foscarnet instead of normal saline. The nurse who gave the infusion was working as a locum tenens – a traveling nurse who spent a few months here and there filling in for others at various hospitals.
The Foscarnet bottle looked strikingly similar to the normal saline product, and I cringed as I imagined how easy it would be for anyone in a hurry to make the same mistake. Unfortunately, Foscarnet is a very powerful anti-viral medication, and infusing a large amount into a small baby could have deadly consequences. In fact, this drug can be toxic to the kidneys and has been known to cause seizures.
What happened after the infusion disturbed me greatly. Instead of telling the parents about the mistake, the terrified nurse begged her supervisor to keep it quiet. I overheard the charge nurse asking the resident to keep the error in confidence, but to keep an eye on the baby for potential signs of toxicity. The resident agreed not to tell anyone, since he feared that he’d ultimately be held responsible or drawn into a lengthy legal battle.
As far as I know the baby didn’t show any overt signs of toxicity – but I worried that the drug could have had a long-term adverse effect on his brain. It certainly can deposit itself in teeth and cause discoloration that lasts a lifetime. At no time were the parents informed of this error. The resident told me not to breathe a word of it to anyone.
I regret that I did not assert myself at the time. I did quietly ask my ethics professor about the issue, and he shifted uncomfortably and said that medical errors weren’t really an ethical dilemma. I tried to present the case to a student group but was told that it would be “inappropriate” to do so. I backed down, and I feel badly to this day about that little baby whom I did not defend to the utmost of my ability. I just hope that his brain is alright and that his teeth were not damaged. I guess I’ll never know.