It was a cold Christmas evening in 2003. My family had just finished eating our second round of Christmas dinner, and I noticed that my stepfather was sitting on the couch and not looking too good. He had been cooking for two days in order to get all the food ready for Christmas day. I asked him what was wrong, and he said he felt like he had a fever. I took his temperature and it was 102°. He deteriorated quickly, so I called the ambulance. He was rushed to the hospital and many tests had to be run. Because he was 47 years old and a 7-year kidney transplant survivor, they had to be very careful about how they treated him to prevent any drug interactions with the 20 medications he took daily. They were able to stabilize him, and my mother and I went home to get some rest.
Fast-forward 2 days and he was still febrile. It was a Sunday and the attending physician did not want to wait for the bronchoscopy test and results to be conducted on Monday, so he ordered an antibiotic to be given ASAP.
My stepfather called my mother and I and updated us on the plan, and we got off the phone saying “I love you, and I’ll see you later.”
What we did not know was that the antibiotic that was ordered was contraindicated with nearly half of the anti-rejection transplant medications my stepfather took daily. The nurse did not question the medication and hung the intravenous drip. Thirty minutes into the infusion, my stepfather went into cardiac arrest and coded. They were able to stabilize him and transfer him to ICU and call the family. My mother and I rushed back to the hospital just in time for the update to say that they were working on him very hard and that we should wait patiently.
As time grew later and later, the nurse in me knew that he was probably already dead and that I should prepare myself and family for the worst news.
After an emotional hour of turmoil, the doctors came out and said that they were unable to revive him. He had coded two more times in the ICU and had passed away. We were told to go say our goodbyes.
After we said our goodbyes, my mom and I walked away from that hospital and swore to never step foot inside that building ever again.
Fast-forward six years later. I was hired as a professor at a local college and was assigned a clinical rotation. I was teaching health assessment to sophomore nursing students working on their bachelors in nursing.
I told my boss my story and said I would go to any hospital in the area; but not the one where my step-father had died.
She sympathized with my loss and promised me that I wouldn’t have to go to that hospital, as there were many others where I could be assigned.
Unfortunately, this was not true. I was called to the office after clinical rotation assignments had been made and was told that I would have to go to that very hospital where my stepfather died, but I would not have to go to the unit where he died. Unfortunately, that was not true either. The hospital had undergone renovations in the last 6 years and I did not remember the exact unit my step-father died on, but when I arrived at the hospital and walked on the unit I was assigned to; I immediately had a panic attack. Although it was 2009, it felt like December 2003 and every possible emotion I felt when I walked on the unit where he coded — consumed me. I realized that I was assigned to the very floor where my stepfather had died from the medication error.
At that moment I had to gather myself, and somehow I was able to tap into some divinely orchestrated strength — and pull myself together.
I approached the nurse’s station and told them who I was and why I was there. For some reason, I wondered if the nurses remembered my step-father. When I worked as an oncology nurse, I know that I never forgot those patients who died — even though in oncology it was often expected and inevitable.
I decided to ask the nurses if they remembered my stepfather, and ironically the nurse who took care of him was there that day. She cried as she told me the story of how she did not double — check the medication for drug-drug interactions, and she just had a gut feeling that she shouldn’t hang it, but also at the moment she felt that the doctor knew best and that she should just follow his orders and give the medication as prescribed.
This was before electronic medical records and scanning, so that process had not yet been instituted as a protective measure for patient safety.
We shared a good cry and I learned a lot from that conversation as well as the one I would have to have with my students when I brought them to the unit the next day.
My step-father’s death became my new “cause” in life.
Because I chose to find the purpose in the pain and honor my stepfather’s story positively:
His story was my thesis topic that I used to complete my MSN program.
His story was what I used to get into the doctoral program and was my first research topic, “Preventing Medication Errors with Electronic Health Care”, before I changed it to disparities in breast cancer, but that’s another story.
His death brings real life application to students learning about medication errors, patient safety, critical thinking and trusting their gut.
His story helps me paint a very vivid and real scenario to nursing leaders about how to do hard things because it’s the right thing to do, even when you don’t want to do it.
His story helps me demonstrate why emotional intelligence is essential and managing your emotions can lead to life-changing answers and solutions.
Ultimately, being transparent about my stepfather’s death has given purpose to the pain my family experienced when he died. Although it’s a very sad and tragic story, his legacy continues to be used for educational purposes that I hope will help prevent another patient’s untimely death.
Dr. Shannon Harrington, RN, PhD, CNE, CEO of T.R.Y. Again Health & Fitness, LLC.
Dr. Harrington specializes in transformational coaching and uses transparent storytelling to bring powerful leadership principles to life. Dr. Harrington teaches holistic leadership strategies and is a sought after author, speaker, and leadership trainer. For more information, please check out her website at www.DrFitNurse.com.