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.
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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.
If they are in the habit of not labeling similar containers, and have been doing it a while, then it is a systems error, especially if this was the way he/she was trained, in addition to a med error on the part of the injector.
But you watch--I am betting the institution blames it on unfortunate human error, rather than bear any of the responsibility themselves. This person is expendable, best not to ruin their reputation and loose money on profitable procedures.
I don't think the one who gave it should be let off the hook. But the system that lead up to the error needs some serious evaluating so it doesn't happen again. Blaming and frying the worker and leaving it at that isn't the best answer.
Each individual needs to be responsible for his or her own actions. It doesn't MATTER how everybody else does it, or how he was trained. Critical thinking would clearly lead to the conclusion that this was an accident waiting to happen--why set yourself up to be the one to make a fatal error, and then cite that "that's how I was taught to do it?"
Consider this: When I worked in the OR before we had sterile labels, we all separated the meds on our back tables by various ways. One might be to put one clear liquid in a metal med cup; the other in a plastic specimen container. Another way was to drop a single, black silk tie in one of the identical containers. A third would be to tear off a piece of a suture packet and drop it in one of the cups. A fourth would be to ask for a sterile marking pen--or, before we had those, a Q-tip and some methylene blue--and MARK the fluids by writing directly on our back tables where the containers sat, and on the containers if possible, or dropping something in one of them (in case the containers shifted.) We would tie a silk tie around the syringe that held any injectable medication. One final way was to drop a syringe cap or other piece of plastic in one of the containers, or put the needle meant for injection in the container of the injectate. No one had to TELL us to incorporate any of these safety measures--we used our own common sense and the materials that we had available.
The possibilities, you see, are limited only by one's own imagination and attention to detail and safety. Sterile marking pens can be found anywhere, as can silk sutures or ties--INCLUDING the radiology department. To be complacent and do things "the way everybody else does them--" KNOWING it's not good patient care--is unacceptable.
One more thing: even with a MASK on, Chlorhexedine has a very distinct SMELL. It is also far more viscous than any radiographic contrast material I have ever seen. Those two factors alone should have made any reasonable and prudent health care practitioner pause, think, and, if there was ANY doubt, throw both solutions out and start over.
this is my systems error article. it's been published in both a legal and a nursing journal, for educational purposes and to stimulate thought among both professions. if it stimulates discussion here about the wisdom of citing "system error--" the pros and cons, as well as conceding that there might be a better way of approaching--or, ideally, avoiding sentinel events--it's served some purpose.
medical and nursing mistakes--professional incompetence, or "systems error?"
as an operating room nurse and legal nurse consultant, i am acutely aware that physicians--particularly
surgeons--are often blamed exclusively for errors that were not their fault.
i can cite from personal clinical experience a situation in which a surgeon was
blamed--and took absolute responsibility for--a surgical fire.
the blame should have fallen not on the surgeon-- not on a "system--" but squarely
on the circulating nurse who added a flammable liquid to the surgical field.
this was a critical error of major proportions, and a careless, unnecessary one
at that. the product that should have been dispensed--stocked in the operating room
for precisely that type of case--was a dehydrated, non-flammable form of
the same product.
the incident is still discussed ad nauseum in various hospitals--things like this
tend to get out, courtesy of busybodies and monday morning quarterbacks, who live
for rumors and innuendo. the details always vary, and get more sensational and graphic
each time the tale is told. however, one thing remains unchanged in the telling--it's
always the surgeon's fault. the surgeon, being the gentleman that he is or perhaps having no choice in the matter,
quietly continues to accept full responsibility for the incident.
why should this be? the nurse involved had an extensive list of excuses, all of
which pointed to "systems error." she accepted no personal or professional responsibility
for her error, nor was she apologetic. management did not suggest that she be held
accountable in any way, and i fear that the nursing union would have shared the
same philosophy. somehow, it became "systems error--" not a failure on the part
of this nurse to be familiar with, and clarify, the drug she was dispensing.
"systems error" has become the 21st century buzzphrase for nurses who would
like to blame anyone and everyone except themselves for their own failures to read
labels and familiarize themselves with the medications they are dispensing. this is basic nursing knowledge--we all learned "the five rights of medication
administration" in nursing school. i am sure physicians have their own horror
stories of inept, incompetent or careless colleagues who cannot and will not accept
personal responsibility for their actions. why should they, as long as they can
deflect blame onto a "system?"
one would like to believe that the archaic "surgeon as captain of the ship" theory
no longer holds water. in most states, it is no longer acceptable as a defense--each
individual is held accountable for his or her own actions. however, this wisdom
has not filtered down into clinical practice, and often the surgeon is blamed by
hospital administration for whatever goes wrong. this is a practice that i find
abhorrent.
i suspect the rationale for this is that the hospital does not want to be the "deep
pockets" if a lawsuit is filed, so if they can claim sovereign immunity and state
that the surgeon was not their employee, they will not be held liable. technically,
they could and should be held liable for the actions of the nurse, who is
their employee--but in most cases that nurse has no personal nursing malpractice
insurance or assets worth going after, and is dismissed as a defendant; if indeed
she was ever even named.
i can see where blaming a "system" could be a useful tool at arbitration--a way
of "spreading the blame" and deflecting the injured party's anger at any one individual.
however, i can also see where it could become a dangerous and unethical game of
spin, with a fair amount of "smoke and mirrors" thrown in for good measure.
health care professionals who cite "systems error" as a way of escaping personal
and professional accountability are an embarrassment to the entire health care profession.
attorneys, arbitrators and health care professionals alike need to band together
to demand professional accountability--and consequences--on an individual
basis for those who would rather blame "a system" for their own incompetence, laziness,
carelessness, inattention to detail, or just plain apathy.
What I have read about this incident was that the cleaning fluid was in a bowl and so was the dye or whatever was to be used for the procedure. The wrong bowl was drawn from into the syringe! How stupid is that!
Was this really a mistake?
I've worked in surgery before and I've NEVER heard of any skin prep solution that's kept in a SYRINGE.
The patient is still dead. This is a fact that no amount of blame shifting will change. Some one pulled the syringe and injected poison into the patient. The person who did could have prevented the error in any one of a hundred ways. The person did not and some one is dead and it may not be their fault but it is their responsibility. I am aware that every one makes mistakes but that does not give any one the right to dodge the consequences of their poor judgments. If this seems to be harsh, consider that the patient received the death penalty.
i wasn't talking about blame shifting...i would think that the person who did the wrong doing should be charged with something...what i don't know. i was reading eariler posts and was saying what i heard happened thats all. those responsible in situations such as this should take the concquences...it makes me mad that this person may only get a slap oon the wrist:angryfire
the patient is still dead. this is a fact that no amount of blame shifting will change. some one pulled the syringe and injected poison into the patient. the person who did could have prevented the error in any one of a hundred ways. the person did not and some one is dead and it may not be their fault but it is their responsibility. i am aware that every one makes mistakes but that does not give any one the right to dodge the consequences of their poor judgments. if this seems to be harsh, consider that the patient received the death penalty.
Also - the last I heard was that the family was NOT going to sue... they were actually quite gracious considering the circimstances. They were upset, rightfully so.... but said that their mother was the type to forgive and move on and that is what she would have wanted them to do... so that is what they are doing.
Oh, they will sue--or they will settle quietly, at arbitration. Trust me, with all the media attention this is getting, the hospital will be falling all over themselves to get the family to accept a settlement before they are bombarded with letters from plaintiff attorneys offering to take on this very high profile case--which will not garner much sympathy for the hospital or their employee once in front of a jury.
And, trust me, it will come out that the reason that the hospital switched to clear Chlohexidine in the first place was to save a few pennies over the brand name product, Hibiclens. Some savvy legal nurse consultant--there are many-- will point it out to the plaintiff attorneys behind the scenes, as well as the fact the many ways a reasonable and prudent person could have avoided the error by way of common sense and critical thinking. All 4 criteria to constitute a meritorious medical malpractice lawsuit--duty, breach of duty, damages and causation--are there in glaring detail. It's a plaintiff attorney's dream.
Would this move--that is, product substitution-- be "systems error?" Not likely. Many hospitals have switched to the cheaper product, and other generic products, since they started becoming readily available in the '90s. Since they've gone THIS long without fatal error--and no other hospital has reported a similar error-- it would be ludicrous to think that excuse would fly now.
Stevierae, good articles, but I nearly spit my coffee on the screen when I read there weren't any med errors in the old days.
I have no problem with taking personal blame and accountability and not making excuses. Still, a responsible organization will look at the process, how this person came to make that med error to see if there is something that they can change.
Stevierae, good articles, but I nearly spit my coffee on the screen when I read there weren't any med errors in the old days.
I have no problem with taking personal blame and accountability and not making excuses. Still, a responsible organization will look at the process, how this person came to make that med error to see if there is something that they can change.
I had a similar reaction (to spitting coffee on the screen, except I wasn't drinking any) to the "no one made med errors".
Having worked in such a hospital I knew a lot of liars, not to mention the hospital corpsman that worked in the pharmacy who dispensed coumadin instead of terbutaline to a woman with preterm labor.
I have a question. Is the person who pours the Chlorhexidine into the bowl the same person who draws it up into a syringe, and the same person who administers it to the patient? Or would more than one person have had the opportunity to realize it wasn't the same as the med that should have been used? As Stevierae pointed out, you'd think the smell and difference in viscosity would have tipped someone off, no?
Specializes in jack of all trades, master of none.
Well, the person who injected F*&^%$ up , BIG TIME, obviously, as he/she killed the pt. All of which most likely could have been avoided, by, as StevieRae pointed out, using the 5 Rights, & labelling his/her containers....
I'm willing to bet that this hospitals P & P states that all meds must be properly labelled, regardless of where the meds are located, be it in a syringe, bowl, bag
Med errors will probably never go away, b/c of the understaffing, the hurry, hurry, hurry, to get 12 hours worth of work done in 8 hours, blah blah blah......
Systems error? Sure, caused by a person not following the basics.....
Just re-read Stevierae's article on system errors.
I agree totally, but I think some fault has to lie in hospital management that runs the hospitals so short staffed. The nurses who have 8 patients and are running around like chickens with their heads cut off are going to try to cut corners - not because they want to endanger patients - but simply because there are not enough hours in their shift to get everything done.
So, while the nurse must take full responsibility for her/his own actions, or inactions, and can't go around blaming or making excuses, I still think they are caught between a rock and a hard place.
I know we have to follow the five rights, but I've also been in situations where nurses have been hurried along - and heaven help the poor nurse who wants to look it up in the PDR! That is not an excuse for not doing it, but we need to have it understood by management that being as careful as we need to be takes time.
Not that any of this perhaps pertains to the death in question, but think it does need to be addressed by management, if they hope to avoid other mistakes. Desperately short staffing is another invitation to disaster.
Stevierae, good articles, but I nearly spit my coffee on the screen when I read there weren't any med errors in the old days.
I have no problem with taking personal blame and accountability and not making excuses. Still, a responsible organization will look at the process, how this person came to make that med error to see if there is something that they can change.
LOL, Tweety, I am not THAT ancient--I am 50--but, I can only speak for the military hospitals where I worked, and I was in the Navy for 6 years. As I stated, we were all very well trained in pharmaceutical math; we checked our calculations with other corpsmen or RNs before dispensing; we read labels and talked with our patients (and these were loooong wards, ORs and emergency rooms) and we knew that anything we did wrong would result in disgrace, the end of military service via dishonorable discharge, and almost certain inability to find a job on the outside because of it. When we came on shift, whoever was dispensing meds that day had a responsibility to go through each and every one of the med cards--hanging on a hook board, by times--and check them for changes, updates, etc. as well as ensuring that they were delivered on TIME.
I remember one occasion--this was in Newport, R.I. somewhere between '73-'75--where the wind from the open window directly across the room blew one of the med cards off a hook and under some surface--or, maybe it was dropped there when the med corpsman was checking the med cards at the beginning of the shift. As a result, a patient did not get her 2 a.m. IM antibiotic. When it was found, luckily in time for the 6 a.m dose (we had to wash the floors in those days, so it was located while cleaning up the nurses' station) the med corpsman duly reported it to the charge nurse, who called the night supervisor, who wrote up a detailed incident report and passed the information on to the ward supervisor when she came in in the a.m. It was a huge, huge deal and the corpsman went to captain's mast and was busted one paygrade. She was removed from direct patient care and placed in an administrative position. It was the scandal of the hospital. In the entire time I was there, that's the only med error I ever heard about.
stevierae
1,085 Posts
Each individual needs to be responsible for his or her own actions. It doesn't MATTER how everybody else does it, or how he was trained. Critical thinking would clearly lead to the conclusion that this was an accident waiting to happen--why set yourself up to be the one to make a fatal error, and then cite that "that's how I was taught to do it?"
Consider this: When I worked in the OR before we had sterile labels, we all separated the meds on our back tables by various ways. One might be to put one clear liquid in a metal med cup; the other in a plastic specimen container. Another way was to drop a single, black silk tie in one of the identical containers. A third would be to tear off a piece of a suture packet and drop it in one of the cups. A fourth would be to ask for a sterile marking pen--or, before we had those, a Q-tip and some methylene blue--and MARK the fluids by writing directly on our back tables where the containers sat, and on the containers if possible, or dropping something in one of them (in case the containers shifted.) We would tie a silk tie around the syringe that held any injectable medication. One final way was to drop a syringe cap or other piece of plastic in one of the containers, or put the needle meant for injection in the container of the injectate. No one had to TELL us to incorporate any of these safety measures--we used our own common sense and the materials that we had available.
The possibilities, you see, are limited only by one's own imagination and attention to detail and safety. Sterile marking pens can be found anywhere, as can silk sutures or ties--INCLUDING the radiology department. To be complacent and do things "the way everybody else does them--" KNOWING it's not good patient care--is unacceptable.
One more thing: even with a MASK on, Chlorhexedine has a very distinct SMELL. It is also far more viscous than any radiographic contrast material I have ever seen. Those two factors alone should have made any reasonable and prudent health care practitioner pause, think, and, if there was ANY doubt, throw both solutions out and start over.