Family Sues After Woman Dies From Mistake At Military Hospital

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You always must watch the heart rate during the test dose. I once had a patient where the heart rate shot up to the 150's from the 80's during the test dose. The epidural was pulled and replaced, this is very important to confirm proper placement.

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:crying2: How horrible. My prayers to the family.
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That's so sad. :crying2: I just can't imagine...

When I was in labor with my 2nd, I had an epidural. They put it in and probably less than a minute later, it suddenly sounded like everyone was far away and in a tunnel. Then I got dizzy and my blood pressure fell quickly. They immediately had me lay down and they took it out. They said it had gotten into a vein.

I'm just wondering how often that happens.

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Specializes in OB, lactation.

That story is awful.

My best friend had a bad epidural experience, it was put in the wrong place and she stopped breathing and her bp bottomed out (she was intubated & emergency sectioned). They are ok now but she missed most of the first day with the baby because they kept baby (& her) for observation/O2. Not to mention the terryifying experience for her & her husband (who is a firefighter/paramedic/flight medic and knew exactly the gravity of what was happening); and a c/s complete with a wound that dehisced after she got home. The anesthesiologist coincidentally either resigned or was fired shortly after (we didn't know the details of why, if her experience was part of it or what).

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how tragic, and how shameful that she had to go thorough all those flights on a "space available" basis, instead of being medevaced via air ambulance or on a commerical flight accompanied by knowledgable health care providers.

my daughter (now 27) was born at tripler, (i was, at the time, a navy corpsman at pearl harbor; tripler was a tri-service, hopsital, serving army, navy, & marine corps, and their dependents.) and i received all my prenatal care there. i had great docs and nurses. how very sad to hear it has deteriorated so much.

from what i have read over the years, tripler has been replacing their military staff with civilian staff. wonder if that has had anything to do with the problems--this is not the first one.

in fact, when i read about the january incident involving co2, i thought to myself, "wait a minute. something is just not right about this." even when i was in the navy, back in '75, o2 tanks were green; nitrogen tanks were black (and very, very large); co2 tanks were, i think, grey (or possibly blue---i cannot recall, for sure) and i believe helium tanks were yellow. we used argon, too (still do) but the color of those tanks escapes me, too.

to complicate things even further, there are medical grade gases and industrial grade gases. industrial grade gases are not generally used in medical situations, but occasionally they get delivered accidentally within a load, and someone mistakenly "adapts" them for use--with tragic results.

unfortunately, those are u.s. standards. colors according to global standards may differ. i am wondering if someone who was used to working in an overseas hospital got used to a different color scheme and "assumed" a tank of a certain color in hawaii was the same as he or she knew it to be in, say, rota, spain---still, i would think the military would have the same product suppliers (including of anesthetic and other compressed gases) everywhere--both europe and the united states, both in hawaiii and the continental u.s.

but i just don't know.

i did some googling, though, and found this article about other tragedies involving compressed gas errors. there are many near misses written about, too. i am copying and pasting this article in its entirety, in the hopes that possibly it may prevent a future tragedy.

guidance for hospitals, nursing homes, and other health care facilities

fda public health advisory

comments and suggestions regarding this document should be submitted within 90 days of publication in the federal register of the notice announcing the availability of the guidance. submit comments to dockets management branch (hfa-305), food and drug administration, 5630 fishers lane, rm. 1061, rockville, md 20852. all comments should be identified with the docket number listed in the notice of availability that publishes in the federal register.

for questions regarding this document contact duane sylvia (301) 594-0095.

u.s. department of health and human services

food and drug administration

center for drug evaluation and research (cder)

march 2001

compliance

additional copies are available from:

office of training and communication

division of drug information, hfd-210

center for drug evaluation and research

food and drug administration

5600 fishers lane

rockville, md 20857

(tel) 301-827-4573

(internet) http://www.fda.gov/cder/guidance/index.htm

guidance for hospitals, nursing homes, and other health care facilities

fda public health advisory1

this guidance represents the food and drug administration's (fda's) current thinking on this topic. it does not create or confer any rights for or on any person and does not operate to bind fda or the public. an alternative approach may be used if such approach satisfies the requirements of the applicable statutes and regulations.

i. introduction

this guidance is intended to alert hospitals, nursing homes, and other health care facilities to the hazards of medical gas mix-ups. the food and drug administration (fda) has received reports during the past 4 years from hospitals and nursing homes involving 7 deaths and 15 injuries to patients who were thought to be receiving medical grade oxygen, but were receiving a different gas (e.g., nitrogen) that had been mistakenly connected to the oxygen supply system. this guidance makes recommendations that will help hospitals, nursing homes, and other health care facilities avoid the tragedies that result from medical gas mix-ups.

ii. background

on december 7, 2000, a nursing home in bellbrook, ohio, reported 2 patient deaths and 8 patients injured following a mix-up in their oxygen supply system. the nursing home had supposedly received a shipment of four cryogenic vessels2 containing medical grade oxygen. included in the delivery, however, was a cryogenic vessel of industrial grade nitrogen. the nursing home was running low on oxygen and sent a maintenance employee to connect a new oxygen vessel to the oxygen supply system. the employee selected the nitrogen vessel and discovered, correctly, that he was unable to connect the vessel to the oxygen system - as a safeguard, the connectors for oxygen vessels are specially fitted so they are compatible only with oxygen delivery systems. the employee removed a fitting from an empty oxygen vessel and installed it on the nitrogen vessel. he then connected the deadly product to the oxygen system. several days later, 2 of the injured patients died from exposure to industrial nitrogen, bringing the death total from this one incident to 4.

on april 22, 1998, a hospital in idaho discovered that a large cryogenic vessel of industrial nitrogen had been connected to the oxygen system supplying the operating rooms, labor and delivery rooms, and emergency room. the hospital discovered that the medical gas delivery person initially had been unable to connect the incompatible nitrogen vessel outlet fitting to the oxygen system, but had used a wrench to disconnect the nitrogen fitting and replace it with an oxygen fitting. two patients died as a result of this medical gas mix-up.

in october 1997, a hospital in nebraska received a shipment of medical grade oxygen in large cryogenic vessels. the shipment included one cryogenic vessel of industrial grade argon that was properly labeled. the hospital was running low on oxygen and sent a maintenance employee to connect an oxygen vessel to the oxygen supply system. without examining the label, the employee selected the argon vessel, and, discovering he was unable to connect the vessel to the oxygen supply system, he removed a fitting from an empty oxygen vessel, installed it on the argon vessel, and connected the deadly product to the oxygen system. argon was administered to a patient undergoing minor surgery. the patient died.

on december 2, 1996, a childrens' home located in new york reported adverse reactions experienced by nine patients due to the inhalation of carbon dioxide. an employee of the home, asked to attach a large cryogenic vessel of medical grade oxygen, unknowingly selected a carbon dioxide vessel from the home's inventory. he noted that the fitting on the carbon dioxide vessel was not compatible with the connector on the oxygen system. nonetheless, he removed an oxygen fitting from an empty vessel, installed it on the carbon dioxide vessel, and attached it to the oxygen supply system. two patients were injured critically, and four patients experienced varying stages of respiratory distress.

all four cases reveal striking similarities:

* the person connecting the vessel to the oxygen system (e.g., the delivery person or the facility employee) was not properly trained and did not understand that connection incompatibility is a built in safeguard.

* prior to installing the cryogenic vessel to the oxygen supply system, the person making the connection did not examine the drug label applied to the cryogenic vessel to ensure that the product was medical oxygen.

the agency has identified additional practices that may contribute to continuing medical gas mix-ups resulting in injury and death:

* although recommended by the compressed gas association, many of the large cryogenic vessels used to contain medical gases do not have permanently brazed, or welded, connections or fittings that cannot be removed.

* unfortunately, not all medical gas vessels are labeled using 360-degree wrap-around labels.

* separate storage areas often are not provided either in the delivering vehicle or at the receiving facility to sufficiently separate medical grade products from industrial grade products.

as a result, many medical gases are improperly or poorly labeled; the wrong gases are delivered accidentally to hospitals, nursing homes, and other health care facilities; and poorly trained personnel are connecting the wrong vessels to oxygen supply systems, despite connection incompatibilities. patients continue to suffer injury or death.

iii. recommendations

all of the incidents described above could have been avoided if a few simple safety procedures had been followed. it is important that all employees handling a medical gas be alerted to and reminded of the possible hazards associated with using medical gas.

the agency recommends implementing the following:

1. if your facility receives medical gas deliveries, you should store medical grade products separately from industrial grade products. the storage area for medical grade products should be well defined with one area for receiving full cryogenic vessels and another area for storing empty vessels.

2. all personnel who will be handling medical gases should be trained to recognize the various medical gas labels. personnel should be trained to examine all labels carefully.

3. if your supplier uses 360-degree wrap-around labels to designate medical oxygen, personnel should be specifically trained to make sure each vessel they connect to the oxygen system bears such a label.

4. make sure that all personnel in your facility who are responsible for changing or installing cryogenic vessels are trained to connect medical gas vessels properly. personnel should understand how vessels are connected to the oxygen supply system and be alerted to the serious consequences of changing connections.

5. you should emphasize repeatedly that the fittings on these vessels should not be changed under any circumstances. if a cryogenic vessel fitting does not seem to connect to the oxygen supply system fitting, the supplier should be contacted immediately. the vessel should be returned to the supplier to determine the fitting or connection problem.

6. once a cryogenic vessel is connected to the oxygen supply system, but prior to introducing the product into the system, a knowledgeable person should ensure that the correct vessel has been connected properly.

we urge you to take every opportunity to promote the importance of properly handling medical gases. alert all personnel in your facility, but especially those who are directly responsible for handling medical gas, to the potential hazards involved.

iv. reporting adverse events or errors to fda

medical gases are prescription drugs. therefore, all medical gas manufacturers who receive reports of death or serious injury associated with the use of medical gases are required under 21 cfr 310.305 and/or 314.80 to report those incidents to the fda.

hospitals, nursing homes, and other health care facilities should submit reports to cder (301-594-0095) or directly to fda_s voluntary reporting program, medwatch, by phone (800) fda-1088, by facsimile (800) fda-0178, or by mail to medwatch, food and drug administration (hfa-2), 5600 fishers lane, rockville, maryland, md, 20857-9787.

1 this guidance was developed by the office of compliance in the center for drug evaluation and research (cder), food and drug administration.

2 cryogenic vessels are used to contain material that is stored at very low temperatures.

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I gave birth to my son Aug 26th,2004 at Tripler...I can't believe that happened to that family. My thoughts go out to that family.

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This is the very reason that, even though we were an active duty military family, I continued to work so I could receive medical benefits from my place of employment. I did not want to utilize military facilities, or practitioners, because the practitioners have no liability if they get sued. The military is like the Catholic Church (I am Catholic, so I can say this), and when there is a problem practitioner, they hand them a new set of orders, and a plane ticket, and move them to another base, where no one knows them, or their past. In fairness, I have met and worked with some fine practitioners, and I really think that the big problem is the system.

I was a flight nurse in the reserves, and I got activated for Desert Storm. We flew two crews per plane, to have adequate personnel. Unfortunately, the AF does not require any specialized previous esperience to be a flight nurse. I was a very experienced critical care nurse, and was appalled at some of the nurses who were flying with me as crew. School nurses, OT nurses, teachers, office nurses, etc. When I was activated, one of the flight nurses on my crew was a nurse who left nursing after only a couple of years, and went to law school. She hadn't touched a patient in years, since going into law. She was worse than worthless in a wartime situation with 120 patients on the C- 141 at 40, 000 feet. They have since started a Critical Care Air Transport Team to transport critical patients, but it was not there 15 years ago. I am so sorry about this situation. It was uncalled for and not necessary. They could have put her in civilian transportation. They are wrong when they say that his rank had nothing to do with this. Officers and their families are treated much better than enlisted. I am an officer, but my husband is enlisted. They have since instituted a differant medical system called Tricare, where you can see civilian pracititionters, in stead of going to the base for treatment. I use Tricare Standard and it works just like civilian insurance, and I have been happy with it. You have to know how to play the system, just like in civilian insurance. They had denied payment for some labwork that I had done for a medication that I take. They said that the labwork was not medically necessary. I made a copy of the medication insert, where it says that this and that were needed to be on this medication. They immediately retracted there objection and paid for the labs. But I was knowledgeable enough to be able to fight it. Most are not.

Unfortuantly, in this situation, this was a young family, and his rank is a definate barrier to objectively complain about practitioners, military staff, etc. I had a problem when my husband had knee surgery several years go. When I complained, I was told by a Chief Master Sergeant, to withdraw my complaint to our congressman, because they would ruin my career and my husbands. My husband had in about 15 years at that point, and did not want to risk losing his entire career, even though I was willing to sacrifice mine. He did not want me to take it further, and I had to withdraw my complaint. So yes, his rank and the military are a factor in this instance, and others, event though the military denies it.

Lindarn, RN, BSN, CCRN

Spokane, WA

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How absolutely horrible. They will all be in my thoughts and prayers.

I wonder how often mistakes with epidurals actually happen. I have had three so far and my hubby is completely wigged out at the prospect of a fourth, he thinks I am playing the odds too much.

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