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.
In synopsis the woman had an asymptomatic cerebral aneurysm that they decided to embolize. The stick was in the groin. The coils were placed, and then contrast (?) was injected to make certain the procedure was effective.
It says the lady was alert and oriented 2 hours later though complaining of pain........
in her swollen leg (?).
Apparently the Hospital is putting a spin on it that is less than believable. I agree that the buck needs to at least linger near the responsible party.
Anyway read this blog and you may get a better handle on the story.
LOL, Tweetie, 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.
Absolutely, you're not that old, 50 is quite young in fact. :rotfl:
In that kind of atmosphere, where disgrace, demotion, etc. resulted do you think maybe more med errors were made and just not reported? I think that's what nurses are trying to get away from here. Rather than humilate the person, use it for a learning experience, find out if there's anything that can be done to stop it from happening again. For example the one who didn't hang the pitocin, perhaps alphabetically is not the best way to arrange drugs, just as drug companies realize same colored med packaging is not a good idea. Helps us humans out.
Here in Florida we have to take CEUs in Med Errors, and I think during my last course I remember reading that in environments that are more learning and supportive, rather than punative (sp?) people are more likely to report med errors. Sorry but I don't have any stats on that. By supportive it doesn't mean you don't address dangerous nurses or mistakes.
But I agree with you 100%. There is a failsafe way to avoid med errors: it's called the five rights (or eight or how many ever there are these days.) Duh..........
Tweety is absolutely right - punative atmospheres only caused med errors to be covered up and not reported - I have witnessed that more than a few times in my life. In an atmosphere where there is less blame and more support not only are the med errors more likely to be reported but there is more likely to be an atmosphere of PREVENTION.
Now just saying "follow the five rights (or 8 rights or however many) does not help in a situation of poor lighting intense pressure to do 5 or more tasks at once, distrations and stressors and finally poorly labelled drugs.
We should be minimizing the potential errors like ensuring that all skin prep is coloured and not looking to vilify one person.
Tweety is absolutely right - punative atmospheres only caused med errors to be covered up and not reported - I have witnessed that more than a few times in my life. In an atmosphere where there is less blame and more support not only are the med errors more likely to be reported but there is more likely to be an atmosphere of PREVENTION.
Now just saying "follow the five rights (or 8 rights or however many) does not help in a situation of poor lighting intense pressure to do 5 or more tasks at once, distrations and stressors and finally poorly labelled drugs.
We should be minimizing the potential errors like ensuring that all skin prep is coloured and not looking to vilify one person.
Points well taken--but there is still something about this particular incident that just does not sit well with me.
Virginia Mason is a renowned, major university affiliated teaching medical center that does a lot of state of the art, high tech procedures. This incident would have taken place in INTERVENTIONAL Radiology, not the plain old X-ray department.
Now, in major medical centers, IR is just as sophisticated as any operating room, and has at least some of the same equipment available that any regular operating room would have--and if it's not readily available, they can call central supply or the operating room and GET it.
I do not know about VM, but many IR departments are run by an OR nurse. I know it was that way at California Pacific Medical Center, as the director of IR used to work at another OR where I had worked. It helps to have someone with OR experience in order to ensure sterile technique, etc.
I can't imagine why any prudent individual would have the same bowl of prep solution--used to prep the groin--on his sterile back table or Mayo stand. Once used, the solution is contaminated. The prep should have been done by a circulating RN or technician in the first place--NOT by the (presumably) gowned and gloved individual performing the procedure. Even if he had to do his own prep, rather than contaminating his sterile gloves he could have done it with sponge sticks saturated with Chlrohexidine, then passed the sponge sticks and no longer needed prep solution off the sterile field.
Now, here's where they could have avoided using liquid Chlorhexidine in the first place--in any major medical center, there is a sterile, self-contained, one step prep solution called Duraprep. It comes in the form of a sterile, single peel packaged plastic "wand" with a sponge on the end containing a solution of Chlorhexidine and isopropyl alcohol. Open it, smack it against the palm of your hand to break the seal and release the solution, prep and discard--all without contaminating your sterile gloves.
Still, citing expense, or just doctors' preference (some docs prefer an old fashioned mechanical scrub) they may have opted to use liquid Chlorhexidine. Nothing wrong with that--but there is something definitely wrong with keeping contaminated prep solution up on the sterile field, and something wrong with not setting it away from the injectate, and definitely something wrong with the individual's sense of smell, etc. I mean, they use this all the time--do this procedure all the time--and yet this particular day he didn't recognize Chlorhexidine by its smell and viscosity? I fear there is more to this story than VM wants us to know here.
One more thing--when Chlorhexidine is used as a prep solution, it is generally diluted with NS, and becomes sudsy. Why would anybody have full-strength Chlorhexidine up on their sterile field in the first place--and, if it was USED prep solution, why did he not recognize it as such, due to its sudsiness? Even if the practitoner himself needed to do a prep at an alternate site during the procedure--say, the neck--normal practice would be to keep CLEAN prep solution--whether diluted or not--on the BACK table until it was needed--NOT up on the Mayo stand with the instruments etc. currently in use. Again, ideally, it would have been another person doing the prep in the FIRST place.
Soemthing is just not right here. Too many unanswered questions.
Points well taken--but there is still something about this particular incident that just does not sit well with me.
Virginia Mason is a renowned, major university affiliated teaching medical center that does a lot of state of the art, high tech procedures. This incident would have taken place in INTERVENTIONAL Radiology, not the plain old X-ray department.
Now, in major medical centers, IR is just as sophisticated as any operating room, and has at least some of the same equipment available that any regular operating room would have--and if it's not readily available, they can call central supply or the operating room and GET it.
I do not know about VM, but many IR departments are run by an OR nurse. I know it was that way at California Pacific Medical Center, as the director of IR used to work at another OR where I had worked. It helps to have someone with OR experience in order to ensure sterile technique, etc.
I can't imagine why any prudent individual would have the same bowl of prep solution--used to prep the groin--on his sterile back table or Mayo stand. Once used, the solution is contaminated. The prep should have been done by a circulating RN or technician in the first place--NOT by the (presumably) gowned and gloved individual performing the procedure. Even if he had to do his own prep, rather than contaminating his sterile gloves he could have done it with sponge sticks saturated with Chlrohexidine, then passed the sponge sticks and no longer needed prep solution off the sterile field.
Now, here's where they could have avoided using liquid Chlorhexidine in the first place--in any major medical center, there is a sterile, self-contained, one step prep solution called Duraprep. It comes in the form of a sterile, single peel packaged plastic "wand" with a sponge on the end containing a solution of Chlorhexidine and isopropyl alcohol. Open it, smack it against the palm of your hand to break the seal and release the solution, prep and discard--all without contaminating your sterile gloves.
Still, citing expense, or just doctors' preference (some docs prefer an old fashioned mechanical scrub) they may have opted to use liquid Chlorhexidine. Nothing wrong with that--but there is something definitely wrong with keeping contaminated prep solution up on the sterile field, and something wrong with not setting it away from the injectate, and definitely something wrong with the individual's sense of smell, etc. I mean, they use this all the time--do this procedure all the time--and yet this particular day he didn't recognize Chlorhexidine by its smell and viscosity? I fear there is more to this story than VM wants us to know here.
One more thing--when Chlorhexidine is used as a prep solution, it is generally diluted with NS, and becomes sudsy. Why would anybody have full-strength Chlorhexidine up on their sterile field in the first place--and, if it was USED prep solution, why did he not recognize it as such, due to its sudsiness? Even if the practitoner himself needed to do a prep at an alternate site during the procedure--say, the neck--normal practice would be to keep CLEAN prep solution--whether diluted or not--on the BACK table until it was needed--NOT up on the Mayo stand with the instruments etc. currently in use. Again, ideally, it would have been another person doing the prep in the FIRST place.
Soemthing is just not right here. Too many unanswered questions.
These are excelent points and very well thought out but in this case it did happen. I totally agree it shouldn't have. I totally agree that there were many ways to prevent this. I also completely agree that someone should have seen and corrected this error in procedure long before it came to the point of causing a sentinel event, however since it has already happened I am sure you are familiar with hindsight is 20/20. I am equally certain that the individual that did the injection feels horrible and is most likly thinking all of the things you are mentioning that could have been done to change the way things were done and probably chewing on a large helping of guilt for not recommending a change before.
My point is you are probably correct in thinking that some greedy Lawyer will talk the family into sueing s/he will likely use their grief and love to convince them that they were wronged horrendously. The fact is it will not lessen the grief or bring their mother back. They will also I am certain be told it is the best thing to do to make sure that this type of thing never happens again, it will serve as a guidline that others will see and then be held accountable for not adhereing to.
The fact of the matter is that as you mention in one of your articles playing Monday moring Quarterback is all too easy for people that weren't there and especially for anyone that is not living with the act of accidentally killing another human being.
The facility is taking the brunt of the blame for sytems error, I am sure the person that actually pushed the cleaning fluid is tremendously sorry, (afterall we can not assume that this person is a heartless villain that hasn't been working in the medical field and trying to help others)and would do or give anything to have the opportunity to change what has happened, but done is done as they say and s/he must live with it and I for one feel that is a pretty harsh penalty (yes I know the Pt got the death penalty) in and of itself. Yes held accountable yes responsible but how much could we really want to puinish a person for this mistake? I put myself in those shoes and feel that I would probably be so full of self doubt that I would most likely not be able to return to my profession, as much as I love my profession and what I do , if I were directly responsible for a death I do not know if i could actually deal with it.
A few years ago an LPN I worked with went to hang a bag of IV NS. She accidentally grabbed a bag of NS for irrigation and hung that. Looked just like an IV bag, but the writing on the bag was in red. In big bold letters it said NOT FOR INJECTION, FOR IRRIGATION ONLY. The LNA that put away the supplies thought it looked like IV stuff, and put it with the IV solutions. The LPN found it in the IV cupboard, and the rest is history. Fortunately there were no ill effect to the patient. We called the manufacturer, poison control, pharmacy etc and nobody could tell us if there would be side effects and what to watch for. Can you imagine that? We just had to wait and see. We did frequent VS and waited. A very frightening experience for all concerned. If a lesson is not learned making an error, the person has wasted their time making the error.
My point is you are probably correct in thinking that some greedy Lawyer will talk the family into sueing s/he will likely use their grief and love to convince them that they were wronged horrendously. The fact is it will not lessen the grief or bring their mother back. They will also I am certain be told it is the best thing to do to make sure that this type of thing never happens again, it will serve as a guidline that others will see and then be held accountable for not adhereing to.
Ummm--they WERE wronged horrendously. I do not think plaintiff lawyers, at least the ones with whom I've worked, are greedy. I think they consider themselves advocates for the catastrophically injured and their families, just as we consider ourselves patient advocates. Granted, there are certainly some bad apples out there, but they are in the minority.
I think that, unfortunately, WILL take a high profile lawsuit to make a difference in this case.
Ummm--they WERE wronged horrendously. I do not think plaintiff lawyers, at least the ones with whom I've worked, are greedy. I think they consider themselves advocates for the catastrophically injured and their families, just as we consider ourselves patient advocates. Granted, there are certainly some bad apples out there, but they are in the minority.
I think that, unfortunately, WILL take a high profile lawsuit to make a difference in this case.
My take is that if the family feels that their Mother would have wanted them to live and let live and if a Lawyer wants to go on the aggressive and hardsell them that there is no other way for the Facility to "Pay The Price" than monetarily then it does become about money! Advocates for the catastrophically injured, at what percent of the verdict?
What I am saying is I know Lawyers just like nurses and everybody else has to make a living, but turning a case like this into a monetary equivalent I feel weakens the entire resolve to make changes and so do better, yes fear of this exact type of reprisal is always and should always be considered, It seems that from what I have read here the family loved their mother and wanted to follow her example of how she would treat the situation had she been alive, a lawsuit would cheapen that IMHO!
A few years ago an LPN I worked with went to hang a bag of IV NS. She accidentally grabbed a bag of NS for irrigation and hung that. Looked just like an IV bag, but the writing on the bag was in red. In big bold letters it said NOT FOR INJECTION, FOR IRRIGATION ONLY. The LNA that put away the supplies thought it looked like IV stuff, and put it with the IV solutions. The LPN found it in the IV cupboard, and the rest is history. Fortunately there were no ill effect to the patient. We called the manufacturer, poison control, pharmacy etc and nobody could tell us if there would be side effects and what to watch for. Can you imagine that? We just had to wait and see. We did frequent VS and waited. A very frightening experience for all concerned. If a lesson is not learned making an error, the person has wasted their time making the error.
pat
You know, truthfully--NS is NS. I can't imagine that there WOULD be any untoward effects, even if the NS was not specifically manufactured and labelled for IV use, and particularly if she only got 1 liter. It probably did not have all the preservatives that some IV NS has, but, then, there are times that you don't necessarily want all those preservatives, either, and specifically request preservative free injectable NS from the pharmacy. I mean, at least SOME portion of the pourable or bagged NS--for irrigation--that we use in surgery is absorbed into the systemic circulation--and, particularly in laparoscopic surgery, we use liter after LITER of NS for irrigation in an open belly. We irrigate grafts meant for implant--including cardiac grafts--with NS for irrigation (NOT IV NS) and we often mix NS for irrigation with contrast to do a cholangiogram. Even though distilled H2O--for irrigation--is labelled "For irrigation ONLY" (and for that matter says, "Unlawful to dispense without a doctor's prescription"--WATER, mind you!) it is still perfectly drinkable.
Still, the fact that there was writing on the label in RED, and the fact that she apparently didn't READ the label, makes this a med error.
I think that, unfortunately, WILL take a high profile lawsuit to make a difference in this case.
To this I would say if you think every facility in the nation will not hear and see about this sentinel event and act accordingly to prevent such circumstances in their facility I would have to say I disagree. I am sure that hours after this story hit the news thousands of facilities had people looking into how they perform and if this could happen to them and took steps to correct.
Possibly unanswered questions for the media and the watching public but perhaps answered in house and for the Sentinel event commitee?
The family has a right to know the truth--not some cleaned up version of it. This is why they will need an attorney--because the hospital will want to keep the details in house, privy only to Risk Management, the Mortality and Morbity Committee, and the Q.A people, who presumably monitor sentinel events.
An attorney, theoretically, could and should be able to elicit the truth of the incident at the depositions of all the culpable players and witnesses. But, the same thing will happen that always happens--hospital counsel will coach them all extensively as to how they should avoid giving anything but "yes" or "no" answers, and they will stall and stall until, finally, when the depositions finally take place, the key players will suddenly claim that "they don't remember."
Ask yourself, "If this were my mom--would I sue?" My mom is no longer living--but, if it had been my mom, you bet I would. Not out of greed, but to hopefully make a point, out of principle, and prevent it from ever happening to anyone else. It would be different if the situation was unavoidable, or if it didn't result in death--but that's not the case here.
P_RN, ADN, RN
6,011 Posts
Here is a good analysis of this tragedy.
http://codeblueblog.blogs.com/codeblueblog/
In synopsis the woman had an asymptomatic cerebral aneurysm that they decided to embolize. The stick was in the groin. The coils were placed, and then contrast (?) was injected to make certain the procedure was effective.
It says the lady was alert and oriented 2 hours later though complaining of pain........
in her swollen leg (?).
Apparently the Hospital is putting a spin on it that is less than believable. I agree that the buck needs to at least linger near the responsible party.
Anyway read this blog and you may get a better handle on the story.