Lancaster Patient Blanks Out after RX Error

By Walter F. Roche Jr.

Seconds after being medicated a Lancaster General Hospital patient became unconscious but not before feeling "pain all over." His blood pressure plunged prompting immediate resuscitation efforts.
Rapid response was called due to the patient's altered mental state and hypotension. He was unresponsive to painful stimuli, the report adds.
After a few minutes the patient began to wake up and related that he could remember nothing except the incredible pain.
The Jan. 16 incident, as related in a state Health Department report, was triggered by an unnamed hospital employee who administered the drug, diazoxide, by injecting it into the patient's Peripherrally Inserted Central Catheter (PICC), speeding the drug directly into his circulatory system.
As the state report notes, diazoxide is a drug meant to be administered orally. In this patient's case that meant injecting the drug into his feeding tube.
The state surveyors, after examining hospital records, noted that the same hospital employee had previously administered the drug correctly.
"She knew it was oral, but somehow confused it on Jan. 16," another hospital employee told the surveyors.
"Based on review of facility documents, medical records and staff interview it was determined that medication orders were not administered in accordance with approved policies and procedures," the report states.
The state surveyors noted that the doctor's orders specified that the drug was to be administered orally.
In its plan of correction hospital officials said staff was re-educated on the importance of route administration. In addition adjustments to equipment were made to make it difficult to deliver drugs incorrectly.
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