如何看待宜兴人民医院护士误将「甲硝唑」当「甘露醇」静滴,导致患儿死亡,官方辞退两名护士?

相关链接:脑炎患儿因输错药死亡

元宿six,专注医学干货和病房故事写作,微信:songs233

说问题前,我们先梳理下整个事件的脉络。

目前有两个事实是存在的,

第一患儿死亡事件真实存在

第二发错药行为真实存在。

这两个地方无需辩解,错就是错,是确凿的医疗事故,但事故等级鉴定结果还在进一步确认。

那么,纠结的问题就在死因和归责上,

先说死因。

孩子的情况网上给出的病例是病毒性脑炎

什么是病毒性脑炎呢?给大众科普下

病毒性脑炎( viral encephalitis,VE)是一种以意识状态改变、发热、癫痫、神经系统缺损、脑脊液细胞增多、神经影像学和脑电图异常等症状为特征的综合征。起病急骤,进展迅速,易造成不同程度的神经系统后遗症,可在短期内死亡,成为严重影响世界共卫生的主要疾病之一[1]

流行病学统计研究显示,病毒性脑炎的每年发病率约为 3.5/10 万~7.4/10 万,且病死率和致残率均较高[2]

对大众来说,知道这个病死率较高要及时救治就好了,你如果光讨论数据,具体到各种表现类型的病毒性脑炎数据又会不一样,讨论这个没有实际意义,篇幅有限我们这里不详细科普了这方面。我们就说说甘露醇和甲硝唑这两在这事件中的作用。

这个病有个特异性症状之一是由于脑细胞水肿导致的颅内压增高,这个在新闻图片里也提到了。

首先说一下甘露醇的作用。因为这个孩子本身被打了病毒性脑炎的诊断,涉及神经系统的基本本身就挺重的,甘露醇是降颅压的,是一个对症疗法,不是说甘露醇用了就一定治得好,但是可以降低颅内压,减少脑组织压力。

至于输错的甲硝唑,是不是因为静脉输注了甲硝唑又进一步导致了颅内压升高、导致病情恶化,这个也没有办法来百分百地论证。

虽然甲硝唑这种药本身不具有致命性损害,但是它在该药说明书中的禁忌症里,也明确表示了有活动性中枢神经系统疾患和血液病者禁用。那么,作为改善脑水肿症状的甘露醇与有可能增加神经系统症状的甲硝唑相对比而言,确实让人觉得在用药方面有点南辕北辙。再退一步,药用错了,那么本该降低的颅内压当时又是否及时采取补救措施,是否延误有效治疗,转院过程中患儿具体状态如何——这些新闻都没有通过详细的病程记录来报道。

新闻只是说“后来医生马上做 CT 检查,发现没问题”。那么如果按这个报告来说的话,确实不是致命原因。

也就是单纯新闻里的这张报告单来看,过错不构成直接后果。而检查报告单之外是什么?新闻里没有报道详细的病程记录。

所以,没必要争执甲硝唑的在这个错误里起了多大作用,现有关于甲硝唑的讨论都缺乏具体情况,只能等最后鉴定结果。

真正让家属不满的是用错药?

用错药这些其实是网络上吃瓜群众的争论焦点,上面已经解释了很多,建议关注这些点在事件调查出来之前没必要再争论。因为受害者的家属气的也不是这个,家属不满的是医院的态度。

值得一提的是,说这些话的家属本身就是医务人员,他们也必定清楚并非用错药这个点导致了全部结局,而且通过采访视频,我觉得真正让他们寒心的可能是转院这件事上的医院补救态度。在发生了医疗事故的情况下,依然没有给出诚恳有力的协助确实不妥,这个换做是谁都忍不下这口气。

而这个时候要是有人对你说,反正错不错都是死?这能忍?

网友的愤怒点是什么,让整个事件升华的地方在哪?为什么发生了那么多起用错药的医疗事故,偏偏今天这个引燃了网络?

因为这位母亲说了这句话。

就算注定要走,多活一分钟也是他的生命。”

谁能反驳一个人求生的权力?讲真,如果是非医务人员可能光顾着闹,很难能表达得如此精准。

人有死的命运,但也有不屈的意志。

我相信这对身为医务人员的父母也曾身披白衣,与死神赛跑。所以他们的目的也不是闹,只是想要个明白的缘由。

是护士的错,但不该以命抵命。

所以,真的,别一窝蜂地都在骂护士了,说什么护士只是辞退太轻了,应该以命抵命。

辞退是医院的处置,刑罚多少还得取决鉴定结果,况且能犯下如此低级的错误,必定不只是最后一关出了问题。事前预备不好,事后善后不够。光上面的对话截图,已经足够说明不只是加错药这个问题。

我们可批评、可以建议、可以处罚,但单纯的辱骂和落井下石只会让其他环节的漏洞被忽略。

护士长解释说甲硝唑和甘露醇这两个长得很相似:

于是直接导致贴标签贴错了,扫码复核也没用了,也可能是急救,就直接拿错备用药了。新闻报道说是护士拿错,最后执行人的错是肯定逃不过的。不可否认,任何个人理由都不能为贴错标签开脱。

但是当最后一个关卡出差,其实也透露着整个系统的问题

我们常见三级医院的给药程序是

从这个程序里我们可以看出,护士其实在病房里除了看护还做了大部分药师的工作,在多数小医院里,还没有开展静配中心给护士减负,即使在三级医院里,也不是所有药都可以通过静配协助(静配多数只提供静脉输注混合药物的配制服务),还有很多内科很多危重情况等不及静配。

所以从某种程度上来说,复杂的混合药物可能审核更多,简单直接输注的药物由于制度原因,可能反而少了一个关卡审核,只能靠忙里忙外的护士自己小心。

像可以直接使用的盐水、甘露醇大部分医院是直接备在病房的,没有经药房多一重审核。但这也是没办法的事,一是时间上可能来不及,二是制度本身和现实情况必须如此。

但总不可能完全都靠最后两个人来把控吧,这就对这家医院的质控系统提出了疑问:护理部平常抽检频率如何?平常有没有备案过应对错误的相应措施,当时输错药后,又做了哪些补救措施?医院质控将如何改进?

把这个错误延伸到漫长的实际工作中,不单单揪着一袋甘露醇。将落脚点放在每个环节中的每个人如何对待错误 。

毕竟现代医疗是各部门各环节通力配合的结果,护士是最后的关卡却不是唯一的关卡,她们平常做的工作量也不比现在的谴责少。

医院虽然是开除了这两个护士,但是法律上的责任是另外追究的,所以别说结果太轻,事件的当事人已经接受了调解,我们应该关注的是今后如何体制的改进,楼上已经有护士说了这方面的建议性意见,如 PDA 扫码操作,厂家外包装改进等。

重压之下错误虽然是难免的,但错了就错了,我们最首要的不是解释苦衷,而是要认得诚恳,认得到位。

担忧之中批评也是难免的,但一味地借批判之名发泄情绪,这样也只能便宜了幕后漏网之鱼。

发帖时间: news

关于 “如何看待宜兴人民医院护士误将「甲硝唑」当「甘露醇」静滴,导致患儿死亡,官方辞退两名护士?” 的 845 个意见

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