Nurses negligent in Minnesota

  1. State Calls Hospital, Nurses Negligent in Patient Death in Minnesota



    State health officials say a Burnsville hospital and its nurses were negligent in the death of a Prior Lake man who received a possibly toxic dose of morphine after elective surgery.

    The man, 37-year-old Edward Kyllonen, died suddenly following hip surgery in November 2001. The state released the results of its investigation earlier this week.

    While the report says Kyllonen received a high dose of the pain killer morphine, it stops short of blaming the death on the drug.

    The Minnesota Health Department found that two nurses at Fairview Ridges Hospital failed to properly monitor Kyllonen as he received morphine and other painkillers following hip surgery. They reportedly administered a total of fifty milligrams of morphine in a 12-hour period, without documenting the dosages, or even asking Kyllonen if he needed more pain medication.

    At six o'clock the next morning a lab technician found Kyllonen unconscious, and not breathing.

    "We never thought this would ever be the outcome," says Mike Kyllonen, the dead man's younger brother. "The surgery itself, yeah, went fine, he came out of the surgery well."

    Investigators also say the hospital and the Dakota County Coroner's Office missed the cause of death-calling it "sudden unexpected death following left hip surgery." Kyllonen's widow sought the investigation by the state's Office of Health Facility Complaints.

    State investigators questioned the results of the autopsy results because it showed no morphine in Kyllonen's blood, despite hospital records that show he had received several doses.

    A new blood test was ordered. It found Kyllonen's blood had toxic levels of morphine that, according to one medical expert, "probably contributed to his death," the report said. Again, the report stopped short of saying the drugs caused the death.

    Kyllonen's family is suing.

    "It is basic nursing practice to properly assess a patient before administer any kind of medication," says Kathleen Flynn Peterson, a former nurse and an attorney representing the family. "This was a totally unnecessary death, this tragedy could have been prevented if they would have just followed their own policies and procedures."


    Story first posted: 7/25/2002 10:37:50 PM

    (Copyright 2002 by KARE. All Rights Reserved.)
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  2. 17 Comments

  3. by   mattsmom81
    I hope a good independent autopsy was done ...I'd like to know the full autopsy results as the article doesn't go into any detail. Isn't it strange one blood sample would come up neg for MS and the other showed toxic?

    Makes me think of am altered circulation state for 2 blood samples to show such opposite effects......maybe the patient had a massive PE or fat embolus, or an MI....?? I hope these nurses get good attorneys who will question this...

    I HATE seeing nurses being blamed for a death and hope this is not the case here...and new evidence comes up to clear them!

    Gotta wonder if a malfunctioning PCA may be involved here as well??

    My heart goes out to the family of this poor man, and the nurses involved, as I'm sure this is a nightmare for them all.

    If you find other articles about this, please post!
  4. by   -jt
    <"It is basic nursing practice to properly assess a patient before administer any kind of medication," says Kathleen Flynn Peterson, a former nurse and an attorney representing the family.>

    Id rather see a former nurse representing other nurses - not prosecuting them.
  5. by   NRSKarenRN
    They reportedly administered a total of fifty milligrams of morphine in a 12-hour period, without documenting the dosages, or even asking Kyllonen if he needed more pain medication.
    Chart must have been reviewed to be order to make this statement.


    ASSESS> REASSESS> DOCUMENT your assessment> DOCUMENT to CYA!!!!

    50 mg not necessarily too large over 12 hours, dependent on body size. Use of pain flow sheets for patients on PCA helpful.

    ??? if assessment done and not documented due to time constraints/staffing issues.

    HUGS to the nurses involved, sure they will need some.
  6. by   rstewart
    I certainly wouldn't want my fingerprints anywhere on that patient's chart. I'm afraid that those nurses are in a good deal of trouble.

    Regardless of the reason for the discrepency between the two blood tests, any mediocre attorney can easily make it appear to be an attempted coverup. Juries hate that.

    I doubt that the facts are exactly as reported in the article. At least I would hope so. For example, I would doubt very seriously that 2 different nurses would each fail to document how much medication that they were giving.

    I am curious as to the ordered morphine dose; From the article it does not appear that the amount given was more than was ordered. Of course, even if the total dose was within ordered parameters, the nurses still had the obligation to assess their patient.

    I am also curious about the code which was no doubt called when he was discovered by the phlebotomist. I wonder whether he had a pulse, if he was given Narcan etc.

    Finally I am curious as to the staffing. Although evidence of poor staffing will not help the nurses in this case, one can not help wonder if this was a factor.
  7. by   NRSKarenRN
    Fairview Ridges Hospital cited in morphine death
    Fairview Ridges Hospital in Burnsville, Minn., has been found negligent by state investigators in the death of 37-year-old Edward Kyllonen. The man had undergone elective hip surgery and received a toxic dose of morphine from two nurses following surgery.

    Minneapolis Star-Tribune,

    http://www.startribune.com/stories/1556/3113994.html


    Most unsetteling in this story is report:

    They also found that two nurses, who were not identified, repeatedly administered morphine and other painkillers through an intravenous drip or morphine pump without documenting why or whether his condition was being properly monitored. He was found in his bed at 6 a.m., unresponsive and not breathing, and couldn't be revived, the report said..............


    The report also accused the hospital of failing to conduct a thorough review of Kyllonen's death, even after it learned that the state was investigating a possible morphine overdose.
  8. by   P_RN
    FIFTY mg of MS sounds like a lot doesn't it, particularly if you are a non-medical juror with an aggressive prosecutor telling you that.

    Our PCA Morphine contained 30 mg MS in 30 cc's. It would not have been unusual at all for a 37y/o to go through one in 4 hours.

    Did it mention if the charting was narrative or computer? I can certainly vouch for the fact that papers from charts go missing all the time.....witness the center of a chart carousel! I've pulled many a page from the carousel!

    Just another form of kick the dog it seems to me.
  9. by   ageless
    50 miligrams of morphine in 12 hours?
    that is 4.16 mg per hour..sounds like there is more to the story that needs to be investigated.
  10. by   Teshiee
    This is tragic! But like I always say cover your azz! Even if he did or not died resulting from the Morphine they did not do any assessing of the patient's vital signs prior or after administration. Lack of documentation states not done. If it came out it was some other cause just the fact they didn't document will screw them in the long run. I really feel for the family I am glad they sought an investigation who wouldn't you don't expect a love one to die from hip surgery!!!!!
  11. by   fedupnurse
    Mattsmom, I thought the same things you did! First thought of the PCA pump. Was it possible that if he was on a PCA pump that he got a large bolus shortly before being found due to a malfunction. I also thought about the fat emboli/PE angle. God knows we see a lot of them after these kinds of surgeries. Sympathies to the families and the nurses involved. I have no doubt there is more to this story.
  12. by   Nurse Ratched
    I know we don't have all the details, but I am still confused. If it was a PCA, wasn't the pt administering his own drugs? Not that that means we aren't assessing him, too. It's been so long since I've worked with one - what is a "standard" 4 hour lockout, for example? I do know we always had Narcan at the beside. I wonder what other pain relievers he was receiving.

    Too much info missing. Sure would like to be a fly on the wall in that courtroom.
  13. by   mattsmom81
    Those nurses who don't work with post op patients on PCA's may not realize that yes...patients in acute pain can go through a 30 mg vial of PCA Morphine in 4-5 hours if the doc allows this in his parameters. So 50 mg in 12 hours would not necessarily be a toxic dose at all...given in 1 mg doses q 15 minutes or so. Now most docs order a lockout interval as well as the above.

    I'm with the rest of ya'll...I still have have a lot of questions. My PCA flowsheets call for asessment of patients drowziness and pain level and VS q 4 h. End of every shift and new vial calls for dosage setting check and witness by 2 nurses. What are your protocols out there?

    I didn't care for that nurses comment either about 'basic nursing care requiring asessment before any dose of med'....as we don't do this before EVERY dose of PCA....she seems to be missing the point of the PCA!!

    I'll be following this and praying for all involved.
  14. by   WashYaHands
    It's been awhile since I've worked with a PCA and heaven knows I'm no expert, but doesn't the PCA pump record a computerized history of the number of patient hits, time and amount of each delivery of the med in addition to the nurses manual charting on the flow sheet? Unless someone cleared the history, this could be a vital piece of info.

    Linda

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