Question raised in my mind aboout "Twilight Zone" case

SICU Queen · Mar 18, 2002

If you're suspicious, then so am I. Of course palms are greased everywhere, and if administration wants to get the heat off of themselves, who better to blame than the nurses? After all, we're on the front lines, so to speak.

Sometimes I get SOOO tired of the bullsh*t that goes along with being a healthcare provider... yuck.

micro, RN · Mar 18, 2002

if something happens.......and the institution is targetted..........sued........then the ........goes downhill...............

"just cause I am paranoid, doesn't mean they aren't out to get me"

nurses.......................CYOA..............................

grouchy · Mar 19, 2002

Oramer - I had a similar thought when I read about the $20,000 hospital liability cap in Massachusetts in the previous Twilight Zone thread. I remember reading that Massachusetts has the highest percentage of nurses reported to the board of nursing.

-jt · Mar 19, 2002

That may very well be coming. That article was just the tip of the ice-berg for that hospital. The whole thing has been blown wide open this week. The newspaper just published findings of its own investigation and turned up several more cases where the transplant recipients died at there, possibly because of poor staffing and inadequate after-care.

The news published reports of cases where families had written the state dept of health complaining about a whole host of issues at that hospital, and other cases of unexpected deaths which the hospital failed to report to the state dept of health.

Many things came to light about this famous "world class" hospital in subsequent news reports this week. There are about 5 other dead transplant pts whose families had been notifying the state of the problems but nothing was done about their complaints on the same issues that led to the donors death. It seems the state has known for quite some time and if they had taken any action, this donor would still be alive.

This weekends newspapers were a very real eye-opener for the non-nursing world. Filled with all the stories of people who died there, the complaints their families made, & whose cases are now being re-investigated.

The family of a man in my community who bled to death post op after his symptoms went unnoticed on the floor & was finally transferred to ICU too late made a complaint to the state months ago & was told that the investigation turned up no problems. Now, because of the news report & investigation, the state has re-opened all these cases. That hospital could find itself shut down. The families will be suing for negligence & whole bunch of other charges, so I wouldnt be surprised if what you say is what ends up happening.

-jt · Mar 20, 2002

Newsday

"Inadequate Care - State cites hospital's treatment of liver donor who died -

Calling his care "shocking" and "fragmented at best," State Health Commissioner Antonia Novello yesterday cited 18 deficiencies in The Mount Sinai Hospital's post-operative care of a patient who died in January, three days after donating a section of his liver to save his brother's life.

While she stopped short of saying the death of Michael Hurewitz, 57, could have been prevented, Novello painted a picture of a transplant unit that was understaffed and too slow to notice or react to his worsening condition. An autopsy showed that Hurewitz had a bacterial infection that had spread throughout his stomach, small intestine, portal vein, esophagus and into his lungs. The infection caused him to aspirate blood into his lungs, killing him.

"The care of the patient was inadequate, and for that we hold Mount Sinai responsible," Novello said in a news conference in Manhattan yesterday.

Hurewitz's widow, Vicky Hurewitz, said in a statement released yesterday that his death was "entirely preventable had proper and timely treatment been instituted by adequately trained, experienced and supervised personnel."

His brother, Adam, 54, of Setauket, chief of pulmonary and critical care medicine at Winthrop-University Hospital in Mineola, has not returned to work since the transplant and is not commenting on the report, said Winthrop spokesman John Broder. The brothers grew up in Rockville Centre; at the time of his death Michael Hurewitz worked as a reporter for the Albany Times-Union. He lived in upstate Schuylerville.

Among the key findings in the report Novello issued yesterday:

The surgeon who operated on Hurewitz at the Manhattan hospital, Dr. Charles Miller, never visited him after the surgery, which is contrary to standard practice and in violation of state regulations.

One surgical resident with only 12 days' experience on the unit was assigned to care for all 34 transplant donors and recipients, a task that left her feeling "totally overwhelmed," Novello said.

The ratio of nurses to patients was 1 to 7, the health commissioner said, compared with a 1 to 1 ratio at University of Rochester Medical Center, which performed the most liver transplants from living donors in the state last year. Novello said there is no required ratio for health care staff to patients.

The transplant fellow - a doctor who is training in a subspecialty - who was on duty failed to respond to the resident's pleas for help when Hurewitz was clearly ill. When the fellow returned to the hospital from a nearby bookstore, he did not examine Hurewitz and instead began a pre-operative workup on another patient.

There was a lack of communication among staff about the patient's diet. Though his chart specified a clear liquid diet, the transplant fellow let the family bring in a full lobster dinner the day after surgery.

The hospital, which performed 35 adult-to-adult living liver donor transplants last year, is being fined $48,000, the maximum possible. Novello said the state had forbidden Mount Sinai from performing such liver transplants for the next six months to ensure that "corrective actions" are taken. Transplants using organs from cadavers or using parts of livers from living adults for children needing transplants will continue, she said.

"I don't believe that, until proven otherwise, we should stop" the hospital's other transplant programs, Novello said.

She said it was "probably customary" that some of the doctors involved would also be reviewed by the health department's Office of Professional Medical Conduct, which can fine a doctor or revoke a medical license. Letters are being sent to the state's three other hospitals that do living liver transplants - New York University Hospitals Center, New York-Presbyterian Hospital, both in Manhattan, and the University of Rochester Medical Center - to ensure they have adequate post-operative care and staffing.

Mount Sinai said in a statement yesterday that correcting problems "is our highest priority. We are deeply distressed that these problems contributed to the death of Mr. Hurewitz and the loss to his family." Barry Freedman, the hospital president, disagreed with the finding that post-operative supervision was inadequate.

Novello said no problems occurred during the operation on Jan. 10, which involved taking about 60 percent of Hurewitz's healthy liver and transplanting it into his brother, who has a liver disease.

But, she said, two days later the otherwise healthy donor developed a rapid heartbeat, which was apparently overlooked by the attending transplant fellow. Around 1 a.m. on Jan. 13, Hurewitz developed hiccups and nausea and was given a medication for the symptoms, which may have masked the underlying problem, the health department report said.

It goes on to say that a surgical resident, unaware of those symptoms, examined Hurewitz at 8:45 a.m. and said his vital signs were stable. Early in the afternoon, Hurewitz began vomiting "brownish materials," generally a sign of blood, Novello said. The surgical resident, who had five months' surgical experience and had been on the unit 12 days, was the only doctor on the unit for three hours, Novello said. The resident called the transplant fellow on duty, who was at a bookstore outside the hospital. He advised against treatment and "despite the patient's distress," the health department said, did not examine Hurewitz upon his return. Hurewitz continued to vomit blood and three hours later was dead.

An autopsy found that Hurewitz was infected with Clostridium perfringens, a bacterium present in the intestines of humans and animals as well as in the soil and sewage. Novello said the health department was still trying to determine the source of the infection.

She added that it was "possible but we just don't know" if Hurewitz's ingestion of a lobster dinner was somehow related to the infection."

http://www.Newsday.com

I still cant believe this hospital just announced LAY-OFFS of personnel - had the audacity to already eliminated 15 vacant RN positions and is planning to reduce even more, as well as other services. Just amazing how they think that even less staffing will solve their problems of already-poor staffing.

see "...Stuck In The Twlight Zone" https://allnurses.com/forums/showthread.php?s=&threadid=14972&pagenumber=1

oramar · Mar 20, 2002

Thanks a lot -jt, I am sure I am getting a lot of information about the case from you that I would not hear otherwise. The more I hear the worse I feel about the whole situation.

oramar · Mar 20, 2002

One more question comes to mind. I wonder if the board and CEO will vote themself a bonus at the end of the year? They porbably will, they should be in jail but they will most likely get a bonus.

-jt · Mar 21, 2002

I wish the magazine Advance For Nurses would put its magazine regional articles on their website too. I sent a mail asking them to do but they havent. Too bad. They just did an article on this situation & I would love to be able to pass it around here so you could see the hospitals rationalization for cutting staff - especially now. Problems with staffing and pt care have been ongoing for a long time & the nurses & other staff have been fighting it through their unions. At Christmas 2000, many support staff were laid off. This January, a healthy post op pt dies needlessly due to poor staffing at this famous, "world-class" facility. And 2 months later the hospital announces MORE lay-offs & elimination of vacant RN positions. It just boggles the mind how they think this is not going to "impact bedside caregiving".

But the following excerpt from the Advance For Nurses article tells us loud & clear where the hospital's priority is:

- re: Mt Sinai's March 4th press release announcing lay-offs:

"Proposed layoffs at Mt Sinai have drawn fire from union nurses at the facility, who plan an informational picket in protest to what the NYSNA is calling "a threat to patient care".... NYSNA nurses at Mt Sinai are currently in contract negotiations and are attempting to develop solutions to the hospital's staffing problems but the management refuses to acknowledge any staffing dilemmas and is continuing with its plan to cut an estimated 450 positions....hospital leaders said the workforce reductions would have a 'minimal impact on bedside caregiving' and would enable the hospital to save approximately $25 million per year.

The facility also said the action would 'provide savings that will significantly reduce the hospital's current deficit and help meet Mt Sinai's long-term goal of achieving a strong financial platform'.

The workforce reductions include management and staff, the hospital said, and were made in response to recommendations by the Hunter Group, a healthcare financial consulting group retained by the Mt Sinai Board of Trustees in 2001 to help the medical center address financial shortcomings."

(Advance For Nurses - NY/NJ edition)

VickyRN, MSN, DNP, RN · Mar 21, 2002

The workforce reductions include management and staff, the hospital said, and were made in response to recommendations by the Hunter Group, a healthcare financial consulting group retained by the Mt Sinai Board of Trustees in 2001 to help the medical center address financial shortcomings."

The HUNTER GROUP..... yick!!! Should have known:(

Leaving their usual trail of carnage and misery and this time, an attributable death.