Hospital admits fault in firefighter's death

Home Health Columnist / Guide · Jan 13, 2002

Coroner's office subpoenas hospital records; autopsy results possible next week

BY LU ANN FRANKLIN Times Correspondent

Posted Saturday, January 12, 2002

http://www.thetimesonline.com/index.pl/article?id=10750531

Firefighter's death under investigation

The Lake County coroner's office subpoenaed Hammond Fire Capt. Michael Magdziarz's hospital records from St. Margaret Mercy Healthcare Centers on Friday.
Magdziarz, 51, of Schererville, underwent successful quadruple bypass heart surgery Monday morning at the Hammond hospital. Later that day, an intensive care nurse administered the wrong medication to Magdziarz through his IV tubing, according to a statement released Thursday by the hospital. He was put on a ventilator, but was declared irreparably brain damaged, Magdziarz's family said. He was pronounced dead at 6:57 p.m. Wednesday after his family signed papers allowing him to be removed from life support.
Although hospital officials aren't generally obligated to turn over patient records, they must produce them when subpoenaed, said Jeffrey Wells, chief deputy for Lake County Coroner David Pastrick.
"We have to have (the records) before we can complete the toxicology," Wells said....

oramar · Jan 13, 2002

from reading this I get the impression that they need autopsy reports to actally verify what they suspect

Home Health Columnist / Guide · Apr 4, 2002

publication date: 03/13/2002

feds cite st. margaret hospital for firefighter's medication death

ask the state to conduct a second investigation.

by bill dolan

times staff writer

http://archive.nextwerk.com/webpublisher21.nsf/59e4ec26071e8a97862567e600248868/2a08f3cc4014ec4a86256b7c000fb9d0?opendocument

hammond -- federal regulators have cited st. margaret mercy healthcare centers for dispensing fatal medication to hammond fire department capt. michael magdziarz in january.

the u.s. centers for medicare and medicaid services will decide whether to penalize the hospital after state health officials conduct a second, more thorough investigation of st. margaret's complete operation, said bob daily, operations manager of the center's chicago regional office, which oversees six midwest states.

"we notified the hospital that they are out of compliance. we don't take action at this time. we ask the state to go back in and do a complete survey of the entire hospital sometime in the near future to see if there are any other deficiencies.

"after that survey is done, we will formally issue the hospital a statement of deficiency for the january complaint and any other findings of the subsequent survey," daily said.

that review, which could be completed within 60 days, will include not only nursing services, but also the hospital's governing body, the physical environment, anesthesiology and emergency care services, he said.

daily said a noncompliant hospital would be in danger of losing federal revenue for treating medicare and medicaid patients.

a hospital spokeswoman declined comment on the report wednesday.

the indiana state health department announced last week it will not sanction st. margaret after concluding an unidentified nurse failed to follow hospital procedures.

magdziarz had been admitted to the hospital the morning of jan. 7, underwent a successful bypass heart surgery and was recovering that afternoon. his surgeon had ordered magdziarz be given a penicillin-like drug to fight infection. instead, the nurse administered tracrium, a neuromuscular blocking agent that was supposed to be given to another patient.

tracrium, which is used to stop violent spasms, can also affect the respiratory system. the report states magdziarz became restless, complained of shortness of breath. within minutes he stopped breathing and suffered cardiopulmonary arrest. he was taken off life support the night of jan. 9.

the lake county coroner's office has classified the 51-year-old schererville man's death as a therapeutic misadventure.

the hospital has responded to the state by taking a number of new precautions, including the placement of warning stickers on packages of all neuromuscular blocking agents.

bill dolan can be reached at [email protected] or (219) 662-5328.

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publication date: 03/15/2002

attorney general investigates nurse in fatal drug case

family of dead firefighter asks state to permanently revoke nurse's license.

by bill dolan

times staff writer

http://archive.nextwerk.com/webpublisher21.nsf/59e4ec26071e8a97862567e600248868/b423f82abe5d1b0286256b7e0014c1ef?opendocument

hammond -- the family of hammond fire department capt. michael magdziarz is asking the state to revoke the medical license of a nurse who dispensed fatal medication to him in january.

magdziarz's daughter is asking the indiana attorney general's office to seek the permanent removal of catherine metzger of calumet city from the nursing profession in indiana for mistakenly administering a paralytic drug meant for another patient at st. margaret mercy healthcare centers in hammond.

"she was careless and negligent. losing her license is a small price to pay for what she has done to my family. i would hate to see this happen to another family," laura magdziarz spisak wrote this week to attorney general steve carter's consumer protection division, in response to a request from that office for information about her father's death.

her letter is the first public identification of the nurse involved in the fatal accident and the first eyewitness account of her father's death struggle in the hospital's intensive care unit the afternoon of jan. 7.

she said she expects her father's fellow firefighters will write to the state to urge the investigation forward, too.

metzger couldn't be reached friday for comment.

stacy schneider, a spokeswoman for attorney general steve carter, said friday she could not comment on any pending investigation of a licensed professional until the office can substantiate the allegations and determine if state law was violated.

sandra golonka, vice president of patient services for st. margaret mercy, declined friday to confirm the identity of the nurse. but she said, "the nurse in question has over 12 years of critical care nursing experience and a solid record of outstanding performance. she made a human error and is devastated. this nurse resigned her position almost immediately after the incident."

schneider said that if her office finds any violations it would file a formal complaint before the state nursing board. "we would present our case, the nurse's attorney would have the opportunity to present their side and then the board makes a decision. they could suspend or revoke a license or put the nurse on probation."

schneider said her office could draw on evidence already gathered by the indiana department of health in its investigation of st. margaret mercy.

the hospital came under fire this week from the u.s. centers for medicare and medicaid services, which cited st. margaret mercy for being out of compliance and has asked the state health department to conduct a more thorough investigation of the hospital's complete operation this spring to see if there are any other deficiencies....

the attorney general's investigation will concentrate on the nurse's role in the incident and her future in the health care profession.

bill dolan can be reached at [email protected] or (219) 662-5328.

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additional story links:

hospital admits fault in firefighter's death

http://archive.nextwerk.com/webpublisher21.nsf/59e4ec26071e8a97862567e600248868/fbbc0198fcd9860e86256b3e001a3a61?opendocument

>>>>>>>>>

publication date: 03/04/2002

state won't sanction hospital for firefighter's death

st. margaret mercy takes steps to prevent recurrence of medication accident.

http://archive.nextwerk.com/webpublisher21.nsf/59e4ec26071e8a97862567e600248868/606a5d9680ff370d86256b73000182ea?opendocument

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publication date: 03/28/2002

nurses get legal refresher course

attorney talks about possible malpractice, wrongful death suits against nurses

by jim masters times correspondent

hammond -- an ohio nursing advocate told a group of nurse practitioners they can no longer claim they were "only following doctors orders" when it comes to defending themselves against malpractice and wrongful death lawsuits.

http://archive.nextwerk.com/webpublisher21.nsf/59e4ec26071e8a97862567e600248868/cb02e10bc65ef79986256b8b00114ab8?opendocument

>>>>>>>>>>>>>>>>>

publication date: 03/29/2002

firefighter's family upset over surprise hospital bill

deceased st. margaret mercy patient charged for resuscitation efforts

http://archive.nextwerk.com/webpublisher21.nsf/59e4ec26071e8a97862567e600248868/5a5d744d295b12c986256b8c0009a343?opendocument

-jt · Apr 4, 2002

To:[email protected]

Regarding the family's comment that the nurse who administered the wrong medication "was careless and negligent": Before I jumped to that conclusion and pin all the blame on the RN, I would want to know WHY this mistake happened. What factors contributed to it?

What is the hospitals practice for dispensing similar-looking medications? Does the hospital store the medications on the unit separately? Were they clearly labeled? Does the pharmacy send the medications up to the unit for each individual patient on as-needed basis or are they all just lying about the medication room shelves? How did the RN come to have another pts medication in this pts room?

Most importantly, how many patients was this nurse responsible for that day? How sick were they? Was this an unmanageable patient load for one nurse to handle? How many hours had she been working? Was she working overtime? If so, was it voluntary or mandatory? Working for too many hours without sleep has been scientifically proven to have a similar effect on a person's thinking and responses as being intoxicated has, but frequently, nurses are forced to work those extra hours (mandatory overtime) under threat of disciplinary action if they refuse, no matter how tired they are.

Was there enough staff working that day & was she allowed time for a meal break? How many hours had it been since she had something to eat? Was the staffing so short that day that she could not have a meal break, as frequently is the case? Going for too long without food lowers a persons blood sugar and can result in poor concentration, among other things.

Every single one of these items has been proven to contribute to medication errors and other patient care errors. Thats why nurses are refusing hospital jobs and why nurses groups, state nurses associations and the American Nurses Association are fighting so hard for state and national laws that ban forced overtime for nurses and legislate safe staffing levels.

So, before I hang the nurse alone, I would want answers from the hospital, and I would want to see the schedule, patient acuity/activity record, and assignment sheet for the day. The nurse may be at fault, but if any of these conditions existed, they contributed to (if not facilitated) her making the mistake and it would be the hospital that is responsible for that.

Im sure youve heard of the shortage of bedside nurses. These working conditions are precisely the reason why. Nurses are bolting from hospital jobs because they are being put into situations everyday by their employers where a tragedy like this is bound to happen again & again.

Nurses do not want any part of a system that leaves them vulnerable to making a mistake and so they are leaving in droves. It may turn out that none of the afore-mentioned factors were involved in this particular case this time, but this kind of tragedy is happening because of these factors and is going to happen more and more unless dangerous management practices like short-staffing to save a buck, and forced overtime are abolished. Until then, nurses will continue to stay home and refuse hospital jobs.

The most frightening thing for me as an RN is I can see how it happened and I know this is not going to be the last case we hear of. I am very sorry for this family's tragic loss and also for the nurse who made the mistake.

Home Health Columnist / Guide · Apr 5, 2002

JT, Your responses are so sharp, articulate and to the point; well done, you covered all the bases. I think you should go to law school to help defend nurses!

3ACCU · Apr 7, 2002

Our facility has "locked" boxes for placement of such medications as neuromuscular blocking agents. They fit nicely in the medication fridge. If it's a med that does not need refridgerated, these types of meds. have their place in our narcotic cupboard. They are signed out. This is one of the "double checks" before administration.

The boxes are clear with a small lock. The key is kept on our narcotic keychain. We were worried that someone would take a mixed volutrol of norcuron instead of an antibiotic! Even if there is enough staff and census is low, the potential for this type of event is present. We changed our policy to protect patients and nurses. This was such a simple solution. It's been in place for a year. The boxes are inexpensive and in any pharmacy catalog. My sympathy goes out to this gentleman's family. My sympathy also goes out to the staff involved.

CindyCCRN · Apr 7, 2002

We are all HUMAN...

...I guess I know inside that this or a similar incident could easily occur in the ICU I work in - as staffing, workloads, and work conditions are UNSAFE and DANGEROUS .... There are many major systems failures that HINDER SAFETY...

(...and yes, that is why I am actively job hunting)...

...This is truly a very sad tragedy - both for the patient and his family AND the nurse and her family... I totally agree with jt that alot of other information and insight into exactly what was going on in that entire unit - entire hospital SYSTEM requires investigation... Obviously, if no one responded to her calls for help after the patient became distressed, all the staff were extremely busy...

Was staffing ADEQUATE? What were the other WORKING CONDITIONS? ...Were both of these patients assigned to this same nurse - did she have others too??? ...Being a long term ICU nurse - I can clearly imagine how many tasks she had to perform in very little time... Proven Fact = "STAFFING" determines ICU Patient Safety... I have no doubt that she IS a very competent and skilled critical care nurse...

Medication Errors are NEVER solely the fault of just 1 person - There is always a whole series of failures that lead up to the error = Root/Cause analysis...

...Were both of these meds dispensed in unit dose and clearly labeled specificially for each patient?

...Was the tracrium ordered as a bolus dose or a continuous infusion? AND was it marked in a bold and bright label with warnings - per manufacturer guidelines?

...Where was the vancomycin infusion stored - next to the tracrium??

..Was it hospital policy that 2 nurses check ALL NMB administration for safety, etc...or would that have been too timely and costly???

...WAS the error immediately recognized and treated - ETT + ventillatory assistance, CPR, etc... PLUS ADEQUATE DOSES OF ANTICHOLINESTERASE REVERSAL AGENTS AT THE RIGHT TIME (10 mins or so) - such as neostigmine?

...I would like to extend my deepest sympathy and many prayers to Mr. Magdziarz and his family and Ms. Metzger and her family...

.....Have the Courage to embrace the truth and ALL it's consequences....

NoeIssa · Dec 10, 2009

Did this nurse lose her license?

Emergency RN · Dec 10, 2009

If the following is correct, then no:

http://www.in.gov/pla/files/May2006.pdf

See page 14 of the PDF file, from the minutes of the Indiana State Board Of Nursing, dated 18 MAY 2006, which details a settlement between the Indiana State Attorney General and the Defendent (Metzger) comprising of a Letter of Reprimand, and three credit hours of continuing education. The BON agreed with the settlement and seconded it.

But honestly, any punishment meted out by any authority could not even come close to the punishment that she is probably giving herself...

SheaTab · Dec 11, 2009

I have one thing to say ...

But for the grace of God go I.

We are all vulnerable to errors like this and worse as long as we continue to allow hospitals to: critically understaff nursing units, push for greater "efficiencies" and removal of so-called waste, and allow our brothers and sisters to continue along the path of burnout.

I can easily see how something like this would happen. Perhaps the nurse pulled two meds up in syringes and failed to label them. In practice and also when family members have been hospitalized, I have noticed that labeling syringes is a rarity. I don't know if this is a phenomenon specific to my locale, but it is quite pervasive. I believe that this is a symptom of burnout to some degree. Many of us have felt pressure to perform more than we were physically and emotionally capable of doing in a given shift. This had led to cutting of corners in as many places as possible in the effort to survive what can be an extremely unpleasant and undoable work-a-day career. I long for the day where nurses will/can stand up and declare that best practices will be the only way they are willing to deliver care. The day where we can say that we don't care how much longer it will take to provide excellent care, because we refuse to give anything less than that.

Nurses, isn't it about time that we take our profession back and refuse to have the administrative masterminds dictate the quality of care we deliver?

My heart goes out to the family of this patient and also to the nurse who made this mistake. I can only imagine how devastated she must feel right now. We have all made errors in terms of medication administration ... it could happen to any one of us and if it hasn't yet, it is only a matter of time.

**canoehead, BSN, RN** · Dec 11, 2009

Based on the OP I wonder why paralytics were even available to the RN when she was looking for an antibiotic.

She called for help and no one responded, but why wasn't there a code blue button to get assistance immediately by the bed?

If she was by the bedside when he stopped breathing, and started BLS right away, it seems like something else went wrong. He was healthy, so if he got attention right away, what happened?