Wash. Woman Dies After Cleaning Fluid Injection

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Full story http://www.reuters.com/newsArticle.jhtml?type=domesticNews&storyID=6913177

Wash. Woman Dies After Cleaning Fluid Injection

LOS ANGELES (Reuters) - A 69-year-old woman who was accidentally injected with a toxic cleaning fluid as she was prepared for surgery at a Seattle area medical center has died as a result, hospital officials said on Wednesday.

Doctors had worked intensively to save the woman since she was mistakenly injected with the solution on Nov. 4, a spokeswoman for Virginia Mason Medical Center said, but were unable to save her.

McClinton was supposed to be injected with a contrast dye to assist in a radiology procedure, but instead was accidentally given a cleansing fluid typically used to prepare the exterior of the body for surgery. Both are clear liquids. The spokeswoman said policies at the hospital had been changed so that the cleansing solution would not be mistaken for the dye again.

::snip::

McClinton was supposed to be injected with a contrast dye to assist in a radiology procedure, but instead was accidentally given a cleansing fluid typically used to prepare the exterior of the body for surgery. Both are clear liquids. The spokeswoman said policies at the hospital had been changed so that the cleansing solution would not be mistaken for the dye again.

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My best guess is that they poured the skin cleaning solution in a sterile cup and the contrast dye into another sterile cup with the intent of swabbing with one and injecting the other. It is so unfortunate that this is still occuring. I seem to recall about a year ago that a similar incident occured when someone mixed up lidocane and epinephrine, I believe that went badly also. This is a bad bad deal. :o

I agree this sounds fishy. To save $ nurses no longer give contrasts in radiology depts around my parts. The techs set up a syringe pump system.

So sad for this woman's family.

The putting both substances in bowls scenario Chad Ky mentioned- that is what happened. This is the same system that caused a death of a six year old in Florida a few years ago. Surprising that any hospitals still do it. I live in Seattle and heard a big local news report about this. It sounded like it was chlorhexidine, and they have since swiched to the single use swabs. So sad :-(

Wonder what will happen to the person responsible? Aside from having to live with that knowledge forever.

This sort of accident sounds familiar. Seems to me 60 minutes did a story about a similar problem that keeps happening for the same reason. I have had quite a few IVPs and it seems to me that at some point in the proceedure the dye is in an open container. It has also bugged me that the tech can inject the contrast. I also have a nuclear scan every few months and the tech can inject the isotope. A nurse comes into put in lock and inject the Lasix (lasix is used in some scans) but a tech can inject the isotope and the contrast dye. It does not make sense.

This terrifies the heck out of me. I swear, if anyone in my family ever needs a procedure I'm going to be hovering so close by.

I feel bad for the woman. I feel bad for the person who made the mistake, but how the heck can you draw cleaning solution?

Sounds to me like some administration was cutting corners somewhere either with storage, or educating employees.

And yes, here rad techs can administer contrast dye.

Why wasn't the skin prep coloured??? Ours is an almost flourescent pink. This was the added effect of marking here the prep has been used.

My best guess is that they poured the skin cleaning solution in a sterile cup and the contrast dye into another sterile cup with the intent of swabbing with one and injecting the other. It is so unfortunate that this is still occuring. I seem to recall about a year ago that a similar incident occured when someone mixed up lidocane and epinephrine, I believe that went badly also. This is a bad bad deal. :o

I work at this hospital, but not in this department.

Chad is right about what happened. Chlorexidine was put on the table near the end of the procedure to clean skin prior to skin closure and was accidentally drawn up and injected in the belief that it was dye.

No angel of death , no doctor vs nurse vs tech injecting issue... A horrible accident with horrible outcomes. Steps were taken that same day to make sure it could not happen again.

Everyone where I work feels awful for the patient, family, and all staff involved.

Seems like there are many precautions that could have been in place to prevent this sort of thing from happenening...I feel just as bad for the person that injected the pt as I do the pt...sigh..

why would these two solutions A. both be clear in colour & placed in containers not labeled ? & B. both be placed on the same table?

Hospitals cutting corners again...so sad. I bet everyone there does feel awful about this.

-Sara

I work at this hospital, but not in this department.

Chad is right about what happened. Chlorexidine was put on the table near the end of the procedure to clean skin prior to skin closure and was accidentally drawn up and injected in the belief that it was dye.

No angel of death , no doctor vs nurse vs tech injecting issue... A horrible accident with horrible outcomes. Steps were taken that same day to make sure it could not happen again.

Everyone where I work feels awful for the patient, family, and all staff involved.

Specializes in Critical Care Baby!!!!!.

Everyone brings up some very valid points, but the thing that sticks out in my mind the most.......why wasn't the syringe CLEARLY marked and labeled? Working in ICU, there are a lot of times when you could have several syringes of medications accessible at any given time. I always label my syringes for this very reason. I am so afraid of making a mistake. This is so sad, and another reason why the 5 rights exist.

Surgical Hrt RN said:
Everyone brings up some very valid points, but the thing that sticks out in my mind the most.......why wasn't the syringe CLEARLY marked and labeled? Working in ICU, there are a lot of times when you could have several syringes of medications accessible at any given time. I always label my syringes for this very reason. I am so afraid of making a mistake. This is so sad, and another reason why the 5 rights exist.

It sounds to me like it wasn't in an unlabeled syringe, it was in an unlabeled bowl and was drawn up with a syringe.

My best guess is that they poured the skin cleaning solution in a sterile cup and the contrast dye into another sterile cup with the intent of swabbing with one and injecting the other. It is so unfortunate that this is still occuring. I seem to recall about a year ago that a similar incident occured when someone mixed up lidocane and epinephrine, I believe that went badly also. This is a bad bad deal. :o

Yes, that makes sense. I remember back when we used to have clear isopropyl alcohol in the operating room--now, in many hospital operating rooms, isopropyl alcohol is tinted BLUE or PINK. I imagine that this was prompted by someone, somewhere, having local and alcohol on their back tables in side by side med cups, and mixed up the two. Nowadays, we also LABEL every solution on our back tables.

I hope that the person who made this grave error accepts full accountability for it instead of blaming "systems error" as is the trend nowadays. But, you watch--I am betting that that is EXACTLY what wil happen.

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