Wash. Woman Dies After Cleaning Fluid Injection

[gwenith]

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.

Article truncated due to copyright laws.

[Tweety, BSN, RN]

You say that the Navy RNs were very highly educated and sophisticated........when I was in the Navy I worked with some nurses fresh out of nursing school that didn't even know how to take vital signs, give meds, or transfer a patient.

Also when I was in the Navy, a friend going for shoulder surgery had requested general anesthetic. The Doc told him no, he was going to give him local anesthetic. During the procedure of giving him local anesthetic, the Doc gave him a pneumothorax and then decided, since the local anesthetic "wasn't working" that he was going to put him under general anesthesia. My friend could have died, as obviously a pnuemothorax plus general = trouble.

Because of the Navy 'no sue' policy, nothing could be done....after my friend spent 2 weeks in the hospital, and had to go back later to redo his surgery.

I have no respect for Navy medicine.

To be honest with you, I wasn't impressed with the nurses when my sister was in a military hospital as a miltary wife having her gallbladder taken out. When I was visiting her a nurse came in a looked at the IV and left, not a word spoken. My sister said that was the only nurse care she'd recieved that day, and it was late afternoon. No assessment was done, no words spoken, didn't even look at the IV site in her arm. I was not impressed. But hopefully no med errors were made.

Before I'm flamed by miliatary nurses, and the multitude of people who have had positive experiences in the military let me offer the disclaimer that I know this to be only an isolated incident.

[CCU NRS]

I was hoping that someone had some updated inof on where the situation has lead from the original incident of the cleaner injection.

[lisawindow]

I know a nurse who works there. The solution was Chlor-Hexadine. In many hospitals we are using it as a skin prep instead of iodine. The Rad Tech had a table with 4 x 4's and an (unlableled) med cup filled with the Chlor-Hexadine on one tray on one side, then on another tray he had the dye in an (unlabeled) med cup and all the procedure equipment. The Rad Tech was not a nurse. He/She didn't go to nursing school, wasn't educated in the five rights of med administration...

[colettea]

I have had the similar experiance working on a tele floor, where a nurse ( rather inexperiance one) was running a Dextose solution that was marked in RED NOT FOR INFUSION...It was to be used in calibration in the hemo lab machines!!!! Pharmacy took that hit on that one cause the stuff shouldn't have been in the Rx in the first place, the nurse was just "spoken to" by the charge on the floor...and the doc that found the iv going was just livid!!! All she had to say was "well that was a learning experinace"! Yeah near death can kinda do that!!!DUH!!! Once again the importance of the 5 rights ( and now the 6 rights) of medication admin.:chair:

[LPN1974, LPN]

Oh, how awful.

Makes you want to think twice about going to the hospital for any tests, doesn't it?

[Mulan]

And I will bet that it is responses like the one you describe (busting the corpsman down a paygrade etc.) that caused people to learn how to be more furtive and cover up their errors, in my not so humble opinion.

I worked with a Navy RN who said she would never report any kind of a med error because it follows one the rest of their career.

I have also seen a lot of errors, etc. by Navy nurses and corpsmen. They are also the first to want to hang someone else, particularly a civilian.

[dukeRN]

I don't know about the USA but here Radiographers (X-ray techs) can give contrast because it is not covered under the therapuetic goods act because it has no therapuetic outcome. And then this happens and they wonder why we nurses kick up a fuss about it.

Anytime someone mentions radiology techs I have to enter my 2cents: anyone care to tell me why they make more money than we do?? I mean, come on!