There are many patient stories in regards to medication and errors. Medication errors result in approximately 700,000 ER visits and 100,000 hospitalizations each year.
Many medication errors are preventable. The following story shows the human tragedy of medication omissions; how the mistake happened, how the mistake was discovered and the consequences for both the patient and the family.
In November 2011, my mother was placed in a nursing home, having suffered a massive stroke. She was transferred to the nursing home from the local hospital after six weeks, as her condition had stabilized, and she required rehabilitation. My mother had not regained her speech, her ability to walk, or to do any independent activities of daily living. The transferring hospital sent all the documentation regarding her medical and pharmaceutical orders for her care management.
Our mother suffered most of her life with depression and was on medication for most of this time. The medication our mother was on, Fluoxetine, was the usual drug she took. Over many years I knew that a side effect of this was that she never cried, even when my father died, her husband of 57 years.
My brother and I became concerned when we noticed she was frequently crying. After experiencing her sobbing on her birthday December 25th, I asked the Nurse for her medicine chart and saw that the Fluoxetine was not being given and initially thought this may have been due to the stroke. I enquired of her doctor, who informed me that the dose had been increased because of the pain after her stroke.
So, for 35 days following admission to the nursing home, my mother had not been given this drug. In other words, she had not been weaned off it but was going through withdrawal, with symptoms that were hugely distressing to her and above all distressing to us. What makes this worse is that she could not speak and tell us; it affects me to this day.
The error was only discovered through my actions. For my brother and I, even all these years, this was a most dreadful time of our lives. Our mother was a great mother, even with her depression. Through her life, she would have fought for us, looked after us when ill, and kept us all healthy.
When dealing with the nursing home, we were made to feel inadequate, at one point being described as liars, hitting brick walls. We were frustrated and extremely helpless. Apart from the distress, we were also labelled as a difficult family. All we wanted was the truth, and now for me, I want to fix the system, regarding a safe method of dealing with a patient’s medication records.
My mother died aged 85, and because of an inadequate system, she had an unnecessary terrible end of life.
Ten years later this event can still have me in tears. My brother and I leave it hanging in the air as it is still very difficult to talk about it. Writing this today brings all those memories back but we did our best under terrible circumstances. I just never know what my mother thought when looking at us with her sad eyes. Did she know we were fighting for her? I am crying again.
Authors Name Withheld, Mon 22 March 2021
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