Potassium error kills newborn

[NRSKarenRN, BSN, RN]

tragic error

hospital mistake kills newborn after heart surgery

by barbara j. durkin

staff writer

february 8, 2002

http://www.newsday.com/news/local/longisland/ny-libaby082580284feb08.story?coll=ny%2dtop%2dheadlines

giovanni and ana celina vargas had never held their newborn baby boy, never seen both his eyes open, when they were summoned to the neonatal intensive care unit at stony brook university hospital on tuesday morning.

they stood in shock as the doctor who had performed life-saving heart surgery on their son just two days earlier told them 6-day-old gianni was dead.

"he told me they made a big mistake," giovanni vargas said. "my baby was dead and he didn't understand what happened."

the couple said stony brook officials told them the next day that their son had accidentally been given a lethal dose of intravenous potassium chloride, 10 times more than he should have gotten, apparently because of a missing decimal point on a prescription.

the state health department said it is investigating the death, and stony brook is conducting its own investigation. david raimondo, the couple's attorney in lake grove, said he would file a notice of their intent to sue today.

"we are sincerely sorry and extend to the grieving family our heartfelt condolences," bruce schroffel, the hospital's director and ceo, said in a written statement. "in spite of numerous safeguards, an error occurred resulting in the tragic loss of a life. we are conducting a thorough investigation of this baby's death to determine what steps are necessary to ensure that this will never happen again."

the brentwood couple, both 27, said they were told by hospital officials that a prescription for potassium chloride read 35 instead of 3.5 and nobody picked up on the mistake.

"everything was checked by professionals at each of three different steps of the process," schroffel said. "we have now doubled the number of professionals at each step."

but the family still doesn't know who wrote the prescription and who administered it. and schroffel yesterday declined to comment on whether staff were disciplined in the wake of the death.

"they told us what happened but they didn't tell us what failed," raimondo said.

yesterday, in their attorney's office, ana celina and giovanni vargas, who married last april, struggled for answers.

giovanni vargas, an ironworker who had been working at ground zero until he was laid off about a month ago, seemed composed as he recounted their son's brief life. though there were people there to translate her words from spanish, ana celina sat mostly silent in despair.

early in the pregnancy, doctors had detected that gianni had a heart valve problem that would require surgery at birth. with a high-risk pregnancy, ana celina vargas went to stony brook weekly, where the couple believed she received good care. "i thought we were in good hands," said giovanni vargas. "i guess we were wrong."

it was a stressful time. "we thought we were going to lose the baby," said giovanni vargas. "i was always asking, do you think we're going to lose this baby? it was a question i couldn't stop asking."

gianni was born by emergency caesarean section jan. 30, full-term, weighing nearly 8 pounds. the heart valve problem was not as serious as doctors had believed, giovanni vargas said.

"he looked great," said vargas, describing a little boy with his mother's coloring, ears and nose and his daddy's straight dark hair.

instead of operating immediately, they put gianni on medication and scheduled the surgery for feb. 3.

the surgery was deemed a success and the hospital staff promised the couple they would soon be bringing their son home. the baby was being given potassium chloride because he had a potassium depletion and they needed to regulate his fluids.

the couple stayed with their son until about 8 p.m. monday. shortly before they left, giovanni vargas saw his son open one eye just for a moment.

that night, ana celina vargas dreamed that something terrible happened to gianni, she said. early the next morning, they got the call: their baby had taken a turn for the worse and they should get there as soon as possible.

"is my baby dead?" vargas said he asked, to no answer.

now the couple wants answers: who wrote the prescription, who gave it, why didn't anyone notice that it was far too much for a baby?

a study in 1999 estimated that medical errors kill about 44,000 to 98,000 people in u.s. hospitals each year, with medication errors the most common problem. a report by the joint commission on accreditation of healthcare organizations, which surveys hospitals across the country, found that potassium chloride was the most frequently implicated drug in medication errors they investigated.

in recent years, there has been much discussion about setting up systems to prevent such errors, said arthur levin, who heads the center for medical consumers, a nonprofit advocacy organization in manhattan.

"if the right system is in place this would not happen," levin said. "there's no excuse for it.... maybe this is an isolated case, but let the hospital tell the public what it's doing [to prevent such cases] and how this happened."

that's what the vargas family wants. "i want to make sure this doesn't happen to any other kids," giovanni vargas said.

the couple sat yesterday with a soft purple keepsake box between them. the hospital had given it to them, filled with the outfit gianni was wearing when he died, a card with his tiny footprints and two photos of him taken after his death. the pictures of him alive had not yet been developed. too much had happened too fast.

on tuesday, ana celina vargas held her baby for the first - and last - time. she clung to him for more than two hours. giovanni vargas didn't want to see his son dead. but by mistake, he turned around and saw him.

"i hugged him for like five, 10 minutes," he said. no, his sister, gently told him. "it was 45 minutes," ivelisse vargas said. "you didn't even realize it."

copyright © 2002, newsday, inc.

bells rang in my head just reading this...20 meq adult standard...35 meq unusual, but for a baby would automatically think too much and i've never worked peds/nicu!

no one questioned this, can't believe it, must have been on autopilot...prepared by nursing or pharmacy??????????

how many hours working, ot?

many system problems here. who administered?

another nurse with license at stake, but what will be done to the doctor???

[oramar]

Wow, this is really shocking. It appears that neither the unit clerk, pharmacist or nurse noticed that 35mcq was out of line. GASP, in a child yet how is that possible? They must all have been very inexperieced. Isn't the doctor the most responsible here, with they pharmacist second and the nurse last? My guess punishment will be metted out in reverse proportion to guilt, with the nurse losing her license, the pharmacist getting a suspension and the doc getting a slap on the wrist. A lot of hospitals are doing without pharmacy staff these days especially on night shift. Could this be a contributing factor? A couple of bone headed mistakes were made where I used to work because the supervisors just did not pick mistakes up like a pharmacist would.

[nightingale, RN]

Was the drug administered as a drip fluid? I shall pray for all those involved, including the family.

I find medication errors on a regular basis... Granted not for potasium.... but .. especially potasium is looked at for the safety level and lab value!

What happened to the safety mechanisms?

B.

[live4today, RN]

What a sad sad case this truly is. Not only does the family need a lot of prayer, the nurse who administered it needs a lot of prayer. My heart just goes out to her. She's probably wanting to step off Planet Earth about now. I know I would if I were in her shoes.

As nurses, we all know how this error occurred. Either that nurse was not a NICU nurse and was pulled to the unit to help out, or she was a new grad with no experience left on her own, or she was overstressed and on overload, worked too many hours without a break for meals or rest???

If this doesn't give the media and the hospital admins a serious wake up call, I don't know what will. How long before they HEAR our cries?

We all know who takes the fall for errors of this kind. Nurse first, pharm second, doctor...well, he'll get off easy. He was 'tired', put the period in but the period wasn't "seen by the naked eye" , or something to cover his butt. The pharm only did what the doc ordered.... , and our poor pitiful nurse "should have questioned the order". Am I right, or what???

Having worked peds and newborn before, any medication order with "whole numbers like 35" should be a light bulb moment in every nurses head, especially when the med is for an infant. She should have said in a loud voice, "35! Is that doctor crazy or what!" We all have made medication errors, but I'm sorry folks, "35" anything would have stopped me in my tracks, and I would have had that doctor eating his words like he'd never eaten them before.

Please pray for that nurse. She needs us right now to do this for her. We don't know the situation entirely, but we do know from past experience that the nurse always pays for the doctors and pharmacys errors in some way or another. God help her!

[NurseDennie, BSN, RN]

My heart goes out to the family and the staff involved in this. Even hearing about a med error like this renews my feeling from nursing school. The instructor told us of a med error that one of our classmates made, ***and the instructor had checked her off on!!!**** I swear, just hearing about it made me want to quietly leave the classroom, go down the back steps, get in my car and never return.

I know that these errors happen, because I was talking with another nurse who told me when she was charge nurse on a unit, standing in the hall and seeing another nurse start to push 30 mEq of potassium into a patient's IV port. She yelled at her, and ran to the room, but the nurse had pushed almost all of it by then. How can this happen? Aren't we all warned and warned and warned again about how deadly potassium is? Yes, of course we are.

Sure -- bells should have gone off in the nurse's mind, but we're all human!! That's why we work in a team situation. And even then, sometimes the system fails. I once almost gave the wrong dose of insulin ... that had been checked and rechecked by other nurses (floor policy). They were just as busy as I was and didn't notice my mistake (right # of units, wrong kind of insulin - I stopped myself going back down the hall...."Hey, this syringe should be cloudy, not clear!" )

The grace of God alone stopped my mistake, and I'll bet if we're honest we'll know that's what stops 95% of our almost-med errors!

We, as nurses, do know why the mistake happened. And, as nurses, we know who is going to be blamed and scape-goated for this. But as nurses, as human beings, we also know what's going on in the heart and mind of the nurse who actually administered the potassium.

I hope somehow she (or he) will know that we know about her (or him) and are praying for her as well as the family and the soul of the sweet baby who died. It's a reminder of the awesome responsibility we hold as nurses. Everybody makes mistakes in their professional life, but our mistakes can have life-changing consequences.

Love

Dennie

[Cascadians]

http://www.freerepublic.com/focus/fr/624091/posts?q=1&&page=51

Hospital mistake kills newborn after heart surgery

That thread now has 100 replies ... fascinating reading responses from Drs and Nurses and other medical workers, and also the public ... quite educational to see the different attitudes.

[nightingale, RN]

Thank you for the post Cascadian! VEry interesting. I had not seen that website before this...

B.

[Cascadians]

Free Republic is the largest and most active Forum on the Internet.

It is HUGE !

Which does make it very interesting whenever a nursing thread or issue comes up, because there is such a variety of types of people responding.

It's sort of a way to keep a pulse on public opinion, although the site is slanted far Republican -- still, any controversial issue tends to garner many responses -- sometimes thousands of posts per thread.

The last couple of years we have noticed many threads about ill parents being hospitalized and their adult sons / daughters realizing their parent is not getting optimal care due to not enough nurses, or that there needs to be a family bedside advocate to keep an eye on things, or that there is more of a push to accept hospice, etc.

So the public is starting to notice ...

And this news about the baby has given them a jolt that mistakes happen

[-jt]

I got this mail from an RN there.......

She calculated the dose factor according to the baby's weight and NEVER had the formula and her orders cosigned by another nurse as is UHSB's protocol. The order then went to pharmacy to be filled. when the pharmacist received and FILLED the order NO FLASHING LIGHTS went off in his or her head that this much potassium SHOULD NEVER go to a neonatal unit.

the 3 safeguards had failed and now many lives will never be the same again and that baby is dead. how very, very sad and disturbing. this nurse was not working overtime. she will probably face manslaughter charges now because although other staff members contributed to this tragedy the nurse ultimately administered the lethal dose.>>

[oramar]

Thanks Cascadians for the link, interesting to read civilian remarks. I like the one that says "the trouble with nurses is that they think that they know more than doctors". That is a remark filled with irony and the person who made it does not even realize it. If a doctor makes a mistake like writing 35 instead of 3.5 we are required to know more than them and fix things. However, if we speak up we are stepping out of our place.

[live4today, RN]

If nurses are expected to know everytime a well paid doctor makes a written error, and we need to go behind them and correct their errors on top of our making sure pharmacy corrects their errors, AND then make sure we are still dutifully following orders to the "T", then why aren't we getting the respect and equal pay as the dumb docs are????

[VickyRN, MSN, DNP, RN]

Was this another case of sloppy writing being incorrectly deciphered (like the penicillin error that resulted in the neonate's death out West?) When, oh when, are we going to REQUIRE Doc's and all PCP's to TYPE OUT ALL THEIR ORDERS. The NP may have intended to write 35mEq's, but then again, this may have been just another careless incidence of SLOPPY PENMANSHIP resulting in a TRAGIC MISTAKE!!!! How many times have you and I tried to decipher doctor's handwriting--how dangerous this is for patients, when one realizes that this same scenario is repeated thousands of times daily in hospitals/pharmacies all over the world!!! I say, enough is enough! Make the doctors TYPE OUT ALL OF THEIR ORDERS and this will lessen the occurrence of such tragic medication errors.