[Update] Nurse Accused Of Reusing Syringes Identified As Chief's Son

By Chaunie Brusie, BSN, RN

Update June 24, 2018, at 4:01PT 

Reports surfaced recently that a nurse at the Cherokee Nation’s W.W. Hastings Hospital in Oklahoma was accused of reusing syringes. Hundreds were tested for HIV and other blood-borne pathogens. The incident was reported to the Oklahoma Board of Nursing and after an investigation, the principal Chief’s son, John Baker, RN, was identified. 

The hospital reported to ABC Tulsa News 8 that John Baker is no longer an employee of the Cherokee Nation and reported that he resigned on May 1, 2018. 

The accused nurse, John Baker, released the following statement, 

"I, John Baker, RN, am deeply sorry that my actions have caused such anxiety to these families. When I understood that I may not have been following proper procedures, I immediately began working with healthcare professionals to identify any mistakes that may have been made and cooperated in every possible way and then I resigned. I love caring for patients and would never knowingly put anyone at risk. My late mother was a nurse and I feel as though I inherited her passion for caring for others. I believe I was called to the nursing profession and I hope to serve patients with the same concern and compassionate care as she did, and I've always hoped she would be proud of the man I am. She and my father always taught me to take responsibility for my actions. As a follower of Jesus Christ, I believe that God offers us all grace and forgiveness and can redeem any situation for the good. God has certainly used this to teach me more humility. I have faith that God will use this situation to improve the care at Cherokee Health systems. Even though the chances of anyone ever being medically impacted by this are extremely remote, I've earnestly prayed night after night for all involved; I pray God's best for you all."

His father, Chief Baker, reportedly seeks an independent analysis and has recused himself from the investigation. He released the following statement, 

"I am deeply saddened by these events and my heart aches for everyone involved. As a father, it is difficult to witness my son experiencing the pain caused by his actions. His decision to pursue a career in service to others continues to fill me with pride to this day. John's honesty, cooperation and acceptance of responsibility ios representative of his values and the quality of man that he is. As Chief of this great nation I know that no one is exempt from the rules. Rules and procedures throughout our nation apply to everyone equally. That is most certainly the case here. I want to strongly encourage anyone who sees wrongdoing of any kind throughout our nation to know their voice will be heard and their concerns will be properly addressed. I'm grateful for the health care workers who helped identify this lapse and their continued service to Cherokee Nation Health Services and the patients they care for."

[Original] June 13, 2018, at 10:59PT

As nurses, medication errors are an everyday threat on the job. We follow procedures like checking and rechecking, scanning wristbands, stating names aloud, and adhering to updated policies on our units. However, every time we encounter a medication, there is a potential for a deadly error. 

An oversite with best practices?

According to the Cherokee Phoenix, a nurse working at W.W. Hastings Hospital committed a very serious medication error that exposed 186 patients to a host of infectious diseases, including HIV and Hepatitis C. The nurse, who has not been named, used the same syringe and medication vial to inject multiple IV bags between patients. She drew out the medication from its vial using a syringe and injected the medication into the patient’s already-hooked up IV bag. She then repeated this process over and over on all of the patients. By injecting the syringe directly into the patient’s IV bag and then inserting it back into the same medication vial, she was potentially sharing countless pathogens that may have been present in the IV bag and tubing among all of the patients that received the medication after. 

However serious her medication error was, a spokesperson for the Cherokee Nation Health Services noted that the possibility that it had caused a direct infection was low. “Patients were never directly in contact with any needle,” the spokesperson told the publication. “In all instances, medication was administered into an IV bag or tubing. The likelihood of bloodborne pathogens traveling up the lines into an IV bag or IV tubing to cause cross contamination from using the same syringe is extremely remote.”

Patient Outcomes

To date, 64 of the 186 patients involved in the incident have received blood testing, with no one showing any exposure. The Cherokee Phoenix reported that the facility called the medication error an “employment matter,” with no news on whether the nurse had received any corrective action or if the individual was still employed with the health facility.

A potentially life-altering error like this one begs the question of: how do mistakes like this happen? Unfortunately, it can be incredibly difficult to say. There could be anything from a nurse being overly pressed for time that day, inadequate policies in the facility, a lack of knowledge on how to administer that medication, to an employee who is not a good fit for the job. But no matter what the exact situation is, as nurses, there are a few things we can do to reduce medication error in our interactions with patients, such as:

Tips To Reduce Medication Errors

1. When in doubt, ask. Don’t assume you know the proper way to administer a medication, especially if it’s something new to you. I once heard a nursing professor tell us as students that it’s never the new nurses that ask questions that scared her; it was the ones who didn’t. Taking the time to double-check with an experienced nurse or reviewing your facility medication administration policy for that specific medication could mean the difference between life and death. 
2. Never try to cut corners when it comes to meds. Medication administration is an area that, as a nurse, you are primarily responsible for. There are so many times I can think of when I was tempted to “speed things along” while giving medications: do I really need to check her armband again? Do I really need to clean that IV port again? I know I have the right med in my pocket…right? And despite my inherent tendency to be lazy, every time, I was glad to have taken the time to double check again. We have all heard the horror stories about medication errors and the majority of the time, they appear to be “simple” errors that could have easily been prevented if the nurse had taken extra time to be safe. 
3. Keep each other accountable. Most of the time, we aren’t working as solo units as a nurse. We are surrounded by co-workers and other staff members and the truth is, we need each other. If you see someone making a potential mistake, don’t be afraid to speak up. Not only could that potentially save a life, but it creates a culture where your co-workers can return the favor to you. 
4. Know that you are not above a medication error. The best way to prevent a medication error? Stay humble. No one is immune to making mistakes and while we may read stories such as this one and think, “That will never happen to me!”, the truth is, a medication error can happen to anyone. Staying humble and being aware of the ways that we put ourselves at risk for an error, such as being understaffed, taking on too much at once, and skipping corners here there, can help us prevent them from happening in the first place. 

Do you have any personal strategies you use to prevent medication errors? 

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