Hospital "Error" Cited in Man's Death - page 2

I found this article "interesting" and it made me made....can someone tell my why the nurse "couldn't find help" and the MD blamed the death on her "guess". (Since I'm not certain of copywrite... Read More

  1. by   kmchugh
    Guys, sorry, but there are a lot of things that just don't ring true about this story. Not saying it didn't happen, but several "facts" seem to be in error.

    First, for those who don't know me, I am a CRNA, and do anesthesia for open heart surgery, among other things. A typical dose of heparin in preparation for going on CPB pump is 25,000 to 35,000 units of heparin. The concentration we routinely use for this is 1000 units per mL. I know, there is 5000 units per mL, but either way, to give 100,000 units, this nurse would have had to given a huge volume (either 100 or 20 cc). Somebody should have noticed that, at least.

    Next, I've done hundreds of traumas, never seen these patients get autotransfusion. For those patients who do get autotransfusion (usually heart or joint replacements), pre-infusion heparin, at any dose, is just not done. But then maybe we just don't do that in Kansas.

    But the biggie is right here:

    "Owens survived the surgery and seemed to stabilize, the report said. But as morning approached, he was bleeding profusely. Surgeons thought he still had an open wound and rushed him back into surgery. He died in the operating room."

    Nope, no way. We check ACT's three minutes after adminstration of CPB doses of heparin, because that's about how long it takes to circulate and have effect. If the patient is not heparin resistant, the ACT 3 minutes after administration will be greater than 450 seconds. If this nurse gave 100,000 units IV heparin in the ER, three minutes later the patient would have begun to bleed out, and within about five minutes, would probably have exsanguinated from five stab wounds. (She had to have given it IV. The volume of 100,000 units, either 20 cc or 100 cc is too great to give by any other route.) Even assuming he made it to the OR, from the first incision, he would have bled profusely. The surgeon would have immediately noticed that something was up. Chances are the anesthetist would have noticed, because the patient could have started bleeding from the moment the laryngoscope was put in his mouth. The patient would not have made it out of the OR, much less come out "stable" to destabilize later.

    Something here is not right. I'd like to know more facts before jumping on the bandwagon.

    Kevin McHugh
    Last edit by kmchugh on Aug 30, '02
  2. by   stevierae
    Kevin, you're right; a lot of things don't ring true about the story.....like, if he was bleeding that badly, wouldn't he have gone to the OR for wound exploration and repair of bleeders?

    And how can you autotransfuse from an open wound in the ER? You could possibly do it via Pleurevac if they put in a chest tube in the ER--the story didn't say where his stab wounds WERE--but, in any case, if he was bleeding THAT badly, he needed to go to the OR. A chest wound like that would have warranted a thoracotomy.

    Now, if he DID have a chest tube placed, and they used one of those Pleurevacs that can reinfuse the blood that is coming from the chest--MAYBE she added the 100,000 U directly to the collection/reinfusion chamber of the Pleurevac.

    If all the blood lost was going directly back into his chest, he would have gotten the entire (overdosage) of heparin.

    But, I'm with you--at that point, he would have been extravasating from every orifice, people would have been yelling for coags, they might have suspected DIC, and I would THINK--wouldn't you?--that they could have recognized it as a massive Heparin overdose, once they got coags back, and at least attempted reversal with Protamine.

    Protamine probably wouldn't have worked, though, with that massive an overdose. Or, would it? I have never seen that massive an overdose, so don't know. I think he would have bled out before they got the coags back.

    I am an operating room nurse and a legal nurse consultant.

    I actually have seen autotransfusion, via Cell Saver, for trauma cases; we do it fairly routinely for splenic and liver lacerations, when there is no bowel involvement. Even the Heparinized NS for Cell Saver is 30,000 U per liter NS, and that is only to wash and process the RBCs; it is not all absorbed by the patient.

    Remember, there ARE 10,000 U per cc Heparin ampules available, although they aren't usually standard floor stock. If she opened 10 of those ampules, common sense should have made her question why she was having to open 10 ampules for one patient.
    Very strange scenario indeed.
    Last edit by stevierae on Aug 30, '02
  3. by   Flo1216
    Why was the nurse the only one to get in trouble? And why didn't the nurse call the pharmacy or look it up? OUr hospital has drug books lying around everywhere.
  4. by   jemb
    http://www.pe.com/localnews/riverside/stories/PE_NEWS_nrowens28.58322.html Maybe this article can answer a few of the questions. It has more detail than the LA Times.

    Local News - Riverside



    Nurse erred, coroner reveals
    SLAYING: A Moreno Valley man stabbed in Riverside received a drug overdose at the county hospital.

    08/28/2002

    By LISA O'NEILL HILL, DOUGLAS E. BEEMAN and JOSE ARBALLO JR.
    THE PRESS-ENTERPRISE


    RIVERSIDE - A man stabbed outside a Riverside gay bar was accidentally given an overdose of an anti-clotting drug at the county hospital, a mistake that contributed to his death, a coroner's investigation has found.

    Jeffery Owens, a gay man who police said was a victim of a hate crime, died June 6 at Riverside County Regional Medical Center in Moreno Valley from a stab wound, according to an autopsy report. But the report also states that an emergency room nurse inadvertently gave Owens 100 times more heparin than he needed.

    Some of Owens' family and friends said they are concerned the findings could complicate prosecution of the five reputed gang members charged in Owens' slaying. Some attorneys representing the defendants said they will try to show Owens, 40, of Moreno Valley died because of the hospital's mistake.

    A hospital official said Tuesday the county medical center has changed a number of procedures to prevent another mistake. The changes include more training, cross checks of dosages and reduced drug supplies immediately available in the emergency department and other hospital units, said Dr. W. Benson Harer, the hospital's chief of staff.


    Jeffery Owens died after being stabbed in June. Police say he was the victim of a hate crime.



    The nurse who made the mistake voluntarily withdrew from working in the emergency room and is on administrative leave, Harer said. The county's human resources office and the state Board of Registered Nursing are looking into her actions, Harer said. No physicians were disciplined.

    "The nurse who was responsible for the overdose was personally devastated when she recognized the extent of the error," Harer said.

    Owens' partner, Jeff Holland, said the information overwhelmed him, even though hospital officials had told him early on about the overdose.

    "I don't think I'm mad at any one person, but things need to be addressed in the hospital system," he said.

    Owens' brother, Robert Owens, said his family was upset by the hospital's mistake.

    "What can be said about something like that?" he said.

    Robert Owens also said he hoped the hospital's error does not take emphasis away from his brother's killers.

    He would not say whether the family plans to sue the hospital. He did say the family is not in settlement negotiations with the hospital.

    Bob Buster, chairman of Riverside County's Board of Supervisors, said hospital officials will be asked to respond to the coroner's findings in two weeks.

    Medication mistakes are among the most common medical errors, health experts say. And heparin is one of the most common drugs with which mistakes are made, according to a study by U.S. Pharmacopeia, a non-profit group that helps to monitor medication errors.

    It is almost never one person's fault, said Matt Grissinger, a medication safety analyst with the nonprofit Institute for Safe Medication Practices.

    "Many things can go wrong -- usually four or five things -- before an error reaches the patient," he said. The Owens case "is a classic example to prove this."

    The parking lot

    The hospital's mistake is the latest revelation in a series of tragedies for the Owens family that began when Owens was stabbed just before midnight June 5 outside The Menagerie. A month after Owens was killed, his mother, Joyce Brown, was found dead in her home. A report on the cause of her death is still pending.

    Owens and others were looking at photographs in the parking lot, police said, when a man approached and punched and stabbed one person in the group, Michael Bussee.

    When Owens confronted the man and several others, an anti-gay slur was said and Owens was stabbed five times, according to police and the autopsy report.

    Bussee has said he and Owens did not realize they had been stabbed until they were on their way back to Owens' home. They were taken in private cars to the county hospital.

    Bussee was treated and released. Owens died after twice undergoing surgery.

    The investigation

    Twelve days after Owens died, a doctor at Riverside County Regional Medical Center notified hospital officials that one of his patients may have been involved in a possible medication overdose, according to the autopsy report. In an interview with the coroner, Dr. David Bolivar, a surgical resident, said he told hospital officials he had overheard a conversation among other doctors discussing a possible medication error.

    Harer, the hospital's chief of staff, said the discussion actually was among operating room nurses.

    Harer said Tuesday heparin was used to prevent clots in a device used to remove blood from Owens' internal wounds so it could be used later during surgery.

    On June 24, the county coroner's office was notified of the medication error, according to the autopsy report. Deputy Coroner Curtis James was assigned to investigate.

    Over the next three weeks, James interviewed Patricia Forst, the nurse who administered the heparin, and four doctors involved in treating Owens.

    Forst could not be reached and her union representative, Linda Love, declined to comment.

    According to the autopsy report, the problem occurred shortly before Owens was taken into the operating room for his first surgery. A chest tube had been installed to drain blood collecting in his chest. When the bleeding persisted and Owens' blood pressure dropped, the nurse asked Bolivar if he wanted to transfuse Owens with his own blood or supplies from the blood bank.

    Bolivar decided to use Owens' blood. The nurse asked Bolivar how much heparin she should administer to keep clots from forming in the collection device. But Bolivar was unable to tell her the correct dose, according to the autopsy report.

    Bolivar has since completed his surgical residency and left the hospital, Harer said. Phone calls to the Bolivar residence were not returned.

    The nurse asked a blood bank worker and a hospital pharmacist for guidance, but neither could provide an answer. She told the coroner's investigator she couldn't find the correct dose in a procedures manual and instructions to the collection device were on the floor, soaked in blood and unreadable.

    "Nobody ever gave me any direction," Forst told deputy coroner James, adding that she thought she was giving 1,000 units, which is protocol.

    Instead, she administered five ampules each containing 20,000 units of heparin, the report stated.

    Dr. Clifton Reeves, the surgeon who operated on Owens, told James he thought Owens would survive. The only noteworthy aspect of the operation was that it took longer than expected to control the bleeding.

    Later that morning Owens' condition deteriorated. He was taken back into the operating room, where he had no detectable blood pressure and he was bleeding internally. He was pronounced dead at 8:36 a.m. June 6, the report stated.

    Reeves said at the time he did not know heparin had been given. He told the investigator that the heparin overdose could have been a factor in Owens' death.

    The consequences

    Riverside County Deputy District Attorney Anne Corrado said the coroner's findings will not affect the criminal case because Owens' assailants started the chain of events that landed him in hospital.

    But attorney Jeff Zimel, who represents defendant Miguel Ramos, said the findings are significant, especially if the defense can show that Owens would have survived.

    "The question is: Were the stab wounds really life threatening?" Zimel said. "That is something that needs to be looked at very closely."

    Staff Writer Tanya Sierra contributed to this report.

    Reach Lisa O'Neill Hill at (909) 368-9462 or loneillhill@pe.com.


















































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    Last edit by jemb on Aug 30, '02
  5. by   ER hippie
    OK, granted I am still a student, but I cannot think of a single scenario that would call for 100,000 units! I can't believe anyone would administer a dose like that, especially to a pt w/ multiple stab wounds. Check, double check, and verify with the MD. And if the MD doesn't know, for god sakes don't administer the drug!!!!!
  6. by   Nurse Ratched
    I also wonder about opening 5 vials of anything - that usually should tip you off. Sad story all around.
  7. by   amyBSN
    this is a very unfortunate story but on my unit heparin and insulin are two meds that we always double check with another nurse.
  8. by   Rustyhammer
    Something in this story is missing or wrong.
    Why, unless very inexperienced or crazy, would she give so much heparin- on a stab victim no less?
    Why, couldn't the MD give her SOME guidance?
    Why, did the pharmacy send 100,000 u to her?
    Why, is the nurse being persacuted alone?
    -Russell
  9. by   ICUBecky
    100,000 units of heparin? this was poor nursing judgement by far, on a stab victim no less. unfortunate. why didn't she ask the charge nurse or call the supervisor(after all that is what they are there for), why didn't she keep on the resident's back to get an order or call the attending physician? i don't get it. opening 5 vials of heparin, should have turned on a light. oh dear. it also looks like she didn't chart very well throughout this whole incident, since the 1st article said she couldn't recall what happened btw. the order for heparin, and giving it. this just keeps getting worse, for that poor nurse. however, i think the surgical resident needs to be questioned too, he never gave a written order, and didn't give the nurse any guidence. i hope she charted what he said to her. in court it won't matter if she was an inexperienced or float nurse...she should have known better. this just gives me a huge reminder to be very careful giving meds and chart everything!

    becky
  10. by   stevierae
    Still something wrong with the scenario.

    I have NEVER seen vials or ampules or Heparin that were 20,000 U per cc.

    For that matter, I have never seen vials or ampules that were 200 Units per cc.

    So, how could she possibly have rationalized opening 5 vials to give what she thought was 1,000 Units?

    And how could her eyesight have been that bad, to misread 20,000 U per cc as 200 U per cc? assuming such vials even existed, which I doubt, in either of those strengths?

    Why would she have not accessed a SINGLE DOSE AMPULE of 1,000 U per cc?

    Or a multidose 30 cc vial containing 1,000 U per cc?

    Volume ALONE should have set off alarms in her head.

    This gross negligence is indefensible.
  11. by   neuro23
    I've worked on wards where Heparin, 10,000 units/ml, is used for DVT prophylaxis (5,000 units BID = 0.5ml s.c.). As a nursing student, this was the only concentration I had experience with. Usually, only student nurses were (are) required to have heparin co-signed (one exception being in pediatrics).

    I now work in ICU and emerg. where we hep-loc central lines with heparin, 1,000 units/ml and we mix heparin gtts using 10,000 units/ml multidose vials. In fact, in all the places I can think of, 10,000 units/ml seems to be the standard (although heparin sodium is also prepared in concentrations of 40,000 units/ml).

    Imagine yourself in the trauma room when a resident gives you a seemingly simple order and says he'll be "right back;" you're unfamiliar with priming a cell-saver, but so is the resident. You call charge's cell ... "busy, please hold" ... you can't ... you call pharmacy; they're also of no help. You need to do something! You page the resident back, overhead. Resident needs to consult his staff ...

    As an RN, you want to help this patient so you get yourself together to find that the only cell-saver has illegible (blood stained) directions. You read what you can, go to retrieve the heparin but there's only 10,000 units/ml bottles available (even though you think you need 2-1/2 vials of 40,000 units/ml) ... so you draw up 10 into a 60 cc syringe and run back to the patient (after 3-4 minutes of reading and drawing up meds) ... you're now in unfamiliar territory ... you make a med error but the resident comes back to thank you for your "fine work;" the pt. needs to go to the OR so you scratch down what was pertinent, e.g. "heparin added to cell-saver as per protocol ..." Next, EMS brings you a stroke in evolution ... could *easily* happen.

    To the best of your knowledge, you have adhered to the six rights of drug admin. You don't know you've made an error so you go on to the next case. The nurse in the article could have been you. Try to put yourself in her shoes ... was she trying her best to help a patient? Did she seek help? Have you ever drawn up several amps to get the right dose? I have.

    Literature supports that co-signing dosages does not decrease error rates -- it becomes routine ... more often than not, the "check" is but a glance at a loaded syringe that contains x units or mls of drug after the first nurse has checked the order or performed the calculation. The verifying nurse then initials, right?

    Rather than blame the nurse in the article, let's think about what we can do tomorrow to prevent a similar tragedy. We're in this profession to help patients. It is absolutely useless to post messages about how perfect we are (none of us is!) It is similarly useless to post messages blaming others. One person stated they wouldn't administer a med unless the dosage was written ... that's a useful point. What else can we learn?

    My two cents: we can become excellent nurses only by focusing on our accountability to the well-being of our patients and by helping our colleagues achieve the same goal.
  12. by   Nightcrawler
    My question isn't with whether this was a med error, as of course it was, but more with why the error wasn't more immediately harmful. The second article stated that they had problems during the original surgery because of excessive bleeding. That I understand, the problem that I have is that heparin has a very short half-life.

    Working post cardiac surgery, we use heparin drips all of the time while pts with mechanical valve replacements are recovering and becoming therapeutic on coumadin, and we draw routine ptt's every 6-8 hours to ensure therapeutic dosage of the heparin. There have been many times when the ptt has come back very high, (usually near the beginning of heparin therapy)you turn off the drip, and the ptt is usually back down to therapeutic, if not all the way back to normal levels within three hours. Ofcourse these people did not receive this high of a dose, but I have seen results in excess of 4500 seconds reverse themselves within 3 hours. If the problem was with the inital overdose of heparin, the patient never ever should have made it out of the first surgery, much less have died hours and hours later during a second surgery. Heparin just doesn't hang around that long.

    Now, it sounds as if the heparin was added to a chest tube in the er, at least from what I have read. In that case, I would have to wonder if the patient was placed on heart/lung bypass during the initial surgery. Pts on bypass are routinely heparinized to prevent clot formation within the machine and during surgery. If the patient did receive ADDITIONAL heparin throughout the surgery because no coags were drawn during the case, then I could see the effects lasting as long as they evidently did.. But if that was the case, then the harm came because no coags were drawn during the case when there was excess bleeding, or after the case to make sure that the patient wasn't in danger of continuing to bleed.

    No argument here that the ED nurse made a HUGE mistake, but for there to be the results that there were in the patients course, it HAD to be just the first in a series of mistakes throughout the process.

    Just my thoughts, but it is often easiest to let the first chain in a series of institutional errors take the fall for all of the rest
  13. by   oramar
    It sounds to me like a lot of people responsible for the error here. It seems like the nurse was the last person on the list and ends up getting the blame. However, most ER nurses I know are aware that 100,000 units is abnormal. The whole bunch of them sound like the gang that could not shoot straight.

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