Hedges, John Walter

Contributing factors

• injection of 5mg morphine into intrathecal port instead of subcutaneous catheter
• unlabeled infusion lines
• failure of second nurse to accompany to bedside for verification
• minimal orientation of agency nurse to hospital
• unclear handover due to foreign accent on recorded message
• similar appearance of two infusion sites without clear differentiation
• flawed hospital procedures for agency staff familiarization
• absence of readily available naloxone prior to incident
• lack of safety alerts or visual identifiers on infusion equipment

Coroner's recommendations

1. Implement labeling of intrathecal lines to clearly distinguish them from subcutaneous access
2. Discontinue use of infusion lines with side ports
3. Attach safety alert cards to pumps to remind staff of intrathecal line presence
4. Mandate bedside handovers rather than recorded tape handovers
5. Ensure naloxone is available on all emergency trolleys throughout the hospital
6. Review and improve procedures for orienting agency nurses to hospital policies and practices
7. Enhance continuing education programs to include case studies of critical incidents
8. Implement auditing processes to monitor compliance with hospital policies
9. Ensure mandatory verification by two nurses at bedside before administration of high-risk medications
10. Provide specialized orientation for nurses unfamiliar with intrathecal medication delivery systems