LA's Martin Luther King nurses gave wrong drug for several days

[NRSKarenRN, BSN, RN]

for days, wrong drug given to los angeles hospital patientlos angeles times, feb. 26, 2004

the latest patient safety error at los angeles' martin luther king jr./drew medical center, in which nurses gave a man a potent anti-cancer drug intended for another patient, comes even as officials at the hospital and the county health department have been assuring regulators that they have fixed problems at the facility.

los angeles times, feb. 26, 2004

for days, potent drug given to wrong king/drew patient

in the latest blunder at the troubled hospital, nurses give anti-cancer medication to a man with meningitis. error renews calls for accountability.

by charles ornstein and tracy weber

times staff writers

february 26, 2004

william watson doesn't have cancer. but for at least four days last week, nurses at martin luther king jr./drew medical center gave the 46-year-old man a potent anti-cancer drug before they realized the medication was intended for another patient.

when the error was discovered, watson said, a nursing supervisor told him: "i want you to sign this paper saying that this had happened, but it had no effect on you." he said he signed the paper, even though he wasn't sure it was true, "because i didn't know what i was doing."

"they told me, 'we can just forget about it, and just squash it like it never happened,' " watson said during a telephone interview from his hospital room. watson, who is uninsured and lives on disability payments, has been at king/drew since jan. 31, suffering from meningitis.

the error comes even as officials at the hospital and the los angeles county health department, which owns the facility, have been assuring regulators that they have fixed problems there.

the hospital is under close scrutiny by state and federal inspectors because of a pattern of lapses in care, including the deaths of five patients last year after a host of errors by nurses and other employees.

county and hospital officials have stressed that paid consultants and a team of top health department managers are on-site at king/drew, which is in willowbrook, just south of watts, to ensure nothing further goes wrong.

after learning of the latest patient-care blunder, county supervisor gloria molina said employees needed to be held accountable.

"it's caught up to them now," she said. "they're just not prepared to meet the mission out there, and they're going to have to move out of the way."

supervisor zev yaroslavsky said that he was running out of ways to express his outrage and frustration that patients continued to be harmed at king/drew.

"you can't argue that this is an anomaly," he said. "it appears to be more normal than an anomaly."

supervisor yvonne brathwaite burke, whose district includes the hospital, expressed anger. but she said she believed that "considerable work" had been done to correct problems at king/drew.

"i don't know that you can correct all of the problems from 25 years in three months," she said. "it's going to take awhile because there's still a lot of people there that have to be removed and there has to be a whole discipline approach-so that when people do something, it has to be in their records so you can hold them accountable. and that has not been done there."

physicians who study how and why medical mistakes occur said the current situation at king/drew makes it ripe for errors. a hospital in turmoil faces more problems preventing errors because it is making so many changes that require learning new systems and procedures, said dr. robert m. wachter, chief of the medical service at uc san francisco medical center and author of a new book on medical mistakes.

"if this particular patient is lucky enough not to be durably harmed by the gleevec, that's just dumb luck," wachter said, referring to the drug that watson received.

gleevec is one in a new generation of cancer drugs that target specific molecules. the drugs are designed to kill cancer cells while avoiding serious damage to normal cells, according to the national cancer institute. gleevec was approved in 2001 for use in patients with a form of leukemia.

county health officials said they were investigating the incident and would decide later this week whether to discipline employees.

"obviously something like this is terrible," said fred leaf, chief operating officer of the county department of health services. "but you can believe, you can bet, that every time something occurs, the safety process doubles.... i think we're doing everything we can to assure there's a safe environment."

a health department spokesman, john wallace, confirmed wednesday that the incident had happened but would not confirm watson's identity, citing privacy rules. he said officials did not yet know if the patient had suffered any harm from taking the medication.

watson said, however, that his eyes were swollen to the size of "golf balls" and that he was unable to see out of one of them.

product information for gleevec notes that one of the side effects is "swelling around the eyes."

geoff cook, a spokesman for novartis oncology, the manufacturer of gleevec, said that if someone without cancer took the drug for four days, "he or she would be unlikely to have any significant long-lasting effects." cook said he did not think swelling would occur after just four days of treatment.

dr. fred millard, an oncologist at the rebecca and john moores uc san diego cancer center, said, "obviously we hate to give people the wrong medicine, but probably it's not really likely to hurt them."

but, he added, "you always wonder a little bit, 10 to 20 years from now, is this going to result in something you didn't expect? if you are otherwise dying from leukemia, that's a risk you're willing to take. what would happen to a normal person, i don't know."

on wednesday, county health officials said an early review of watson's case showed the systems designed to protect patients had broken down and individual employees had not performed their duties properly.

doctors did not order the drug. they did not realize watson had been given it. nurses administered the drug for at least four days without checking for a doctor's order. and pharmacists filled the order incorrectly and didn't realize their mistake.

county officials, who did not identify watson by name, provided this account of what happened: watson apparently had been given a drug ordered for another patient. when gleevec did not appear on the other patient's medication record, a nurse alerted the pharmacy, which created a second order for the drug.

no one checked to see who was getting the first order, and watson continued to receive gleevec, along with medicine for his meningitis. wallace said the two patients' names are not similar, so that would not account for the error.

gleevec first appeared on watson's medication record on feb. 12, but a nurse crossed it out, noting that it had not been ordered for him. a second nurse took the same action a day later.

between feb. 14 and 17, different nurses gave the man gleevec, even though there was no doctor's order. on feb. 18, a nurse again noticed the problem and alerted the pharmacy, which began to investigate.

"it's not explainable right now," wallace said.

the california department of health services was notified wednesday of the incident, a manager said, but was waiting for additional information before deciding how to proceed.

the county health department said it had made immediate changes to prevent the mistake from reoccurring. the pharmacy, for instance, is now required to check each patient's medication record each day for potential mistakes and to ensure that drugs have been administered. and physicians are instructed to review patients' medications daily.

supervisor molina said she didn't know how much more leeway federal and state regulators would give king/drew.

"if doctors, nurses and administrators keep failing us, this hospital is going to sink," molina said. "that's my fear."

http://www.latimes.com/news/printedition/california/la-me-kingdrew26feb26,1,7203571.story?coll=la-headlines-pe-california

[pickledpepperRN]

I talked with a reporter at the LA Times.

Because these errors happen at many other facilities I was concerned that the county hospitals were being singled out.

The theory was that the private hospitals advertise in the paper.

[purplemania, BSN, RN]

and what about the poor pt. who SHOULD have gotten the RX?

[pickledpepperRN]

These are absolutely terrible.

The article states, " When Gleevec did not appear on the other patient's medication record, a nurse alerted the pharmacy, which created a second order for the drug."

Perhaps the pharmacy was so busy that either the system or human error caused the busy pharmacist to forget to check what happened to the original order.

Also in the article, "Gleevec first appeared on Watson's medication record on Feb. 12, but a nurse crossed it out, noting that it had not been ordered for him. A second nurse took the same action a day later.

Between Feb. 14 and 17, different nurses gave the man Gleevec, even though there was no doctor's order. On Feb. 18, a nurse again noticed the problem and alerted the pharmacy, which began to investigate."

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To me the worst part is the attempt at covering it up instead of admitting problems and changing the system and staffing so such errors don't continue to happen.

Many hospitals do the same thing. The public needs to be very frightened. A facility will spend on consultants and technology without respecting their direct care staff.

In the mid 1990s at one hospital a unit moved into a new building, "Patient Focused Care" was initiated requiring registetred nurses to care for up to 12 patients with an unlicensed assistant (the day befor the maximum was 6), and 40% of the pharmacy staff was laid off.

Medication errors doubled and the solution was to discipline nurses!

We had filled out 'Assignment despite objection" forms placing responsibility on the facility for harm to patients due to the nursing staff reporting this assignment that placed the patients at risk.