Video Transcript: 'The Night of Many Codes'

[Excerpt from Beyond Blame, a film produced by Bridge Medical, Inc., and distributed by the Institute for Safe Medication Practices.]

DENNIS DUNN, RPh, Hospital Pharmacist: There was a night � they referred to it as the night of many codes. There were four codes in the hospital (codes meaning emergencies where people needed to be resuscitated), and there was a possibility that these four patients might have been given a drug in error. And since the medications were dispensed on my tour � they were IV medications � I reported it and took the responsibility. One patient died two days later, another patient died about a month later, and the other two patients survived.

When I realized that the error was my responsibility, it was total devastation. It�s the biggest nightmare to hurt somebody. And I got a call from a contact of mine at another VA [Veterans Affairs] hospital, and he advised me to go immediately and resign, because they were going to fire me that afternoon. The word had been passed down from on high that I was not to be hired under any circumstances, so then I was really out in the cold.

MICHAEL R. COHEN, MS, FASHP, President, Institute for Safe Medication Practices: What happened in the Denny Dunn case was primarily a packaging issue. For a number of years, the hospital had been using an antibiotic known as metronidazole, which was well-wrapped. Without any knowledge of the pharmacist or the pharmacy staff, a new medication was brought in called mivacurium, which is a paralyzing agent, a neuromuscular blocker, and it was in identical packaging. And neither of the packaging had real clear information about what the drugs actually were. The names weren�t visible.

DENNIS DUNN: That assured an accident or error was going to happen. The only thing was, who was going to be the unlucky one. And that, by fate, was me.