Chektorolac Case Summary
Fifteen year old Lewis Blackman died after a minimally invasive surgery. The cause of death was due to perforated bowel caused by ketorolac, a highly potent non-steroidal anti-inflammatory to treat pain and inflammation and for its potential for stomach ulceration. As I read the case, I noticed the following system failures that lead to this sentinel event.
First, ketorolac has a black box warning “not to be used in pediatric patients.” 1 A black box warning is the strictest warning put in the labeling of prescription drugs by the Food and Drug Administration when there is reasonable evidence of an association of a serious hazard with the drug. Having the black box around the warning means that an adverse reaction to the drug may lead to death or serious injury.2 Lewis also had low urine output post-surgery another reason ketorolac should not have been used due to ketorolac’s potentiation of renal toxicity.1
With that, this drug was used with no observed cautionary measures conducted. Lewis never received a hands on assessment to determine the severity of his symptoms, checked for side effects and/or pain. Instead, Lewis’ occurring symptoms were dismissed and unqualified personnel (nurses) diagnosed his symptoms as “gas pains” with the assumption that all patients are the same, a concept known as anchoring, being fixed in a
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Ironically, the hospital wanted to make sure they got a good score on Joint Commission as a patient was dying in the next room due to a medication error. The case of Lewis Blackman is now a teaching tool to nurses and other members of the medical team on cognitive barriers we can have while delivery care and we all need to focus on our decision making skills to ensure red flags are not missed to keep patients
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