An 18-month-old child was admitted to the hospital after falling into a hot bath. Two weeks later, she was doing well and set to return home. Her mother noticed that the little girl asked for a drink every time she saw one, and she often sucked on a wet washcloth. When the child’s mother asked about this behavior, the nurses told her it was normal—they would not ask a physician for permission to give the girl a drink. The nurses told the mother that her child was doing well and that she should go home and get some sleep. When the mother returned early the next morning, she knew that something was very wrong with her child. The medical team was notified. They administered naloxone, a drug used to block the effects of opioids. They finally allowed the girl to have a drink, and she swallowed a liter of juice. The medical team determined that the girl should not be given any more narcotics. They gave verbal orders. A nurse entered the girl’s room that afternoon with a syringe of methadone. The mother reminded her that no narcotics were to be given. The nurse said that the orders had been changed and gave the little girl the drug. It was not long before her heart stopped. The girl died in her mother’s arms two days later. Along with the narcotics, she had a hospital- acquired infection and was severely dehydrated. 3. How could the girl’s death have been prevented? What measures would you put in place to make sure this did not happen to another patient?
An 18-month-old child was admitted to the hospital after falling into a hot bath. Two weeks
later, she was doing well and set to return home. Her mother noticed that the little girl asked
for a drink every time she saw one, and she often sucked on a wet washcloth. When the
child’s mother asked about this behavior, the nurses told her it was normal—they would not
ask a physician for permission to give the girl a drink. The nurses told the mother that her
child was doing well and that she should go home and get some sleep.
When the mother returned early the next morning, she knew that something was very
wrong with her child. The medical team was notified. They administered naloxone, a drug
used to block the effects of opioids. They finally allowed the girl to have a drink, and she
swallowed a liter of juice. The medical team determined that the girl should not be given any
more narcotics. They gave verbal orders.
A nurse entered the girl’s room that afternoon with a syringe of methadone. The mother
reminded her that no narcotics were to be given. The nurse said that the orders had been
changed and gave the little girl the drug. It was not long before her heart stopped. The girl
died in her mother’s arms two days later. Along with the narcotics, she had a hospital-
acquired infection and was severely dehydrated.
3. How could the girl’s death have been prevented? What measures would you put in
place to make sure this did not happen to another patient?
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