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.
As I see it, the disagreement on this thread is coming about because of divergent opinions on two issues:
1. That anyone can make a med error (or not) given the "right" conditions.
2. That "systems error" approach is good (or not).
No matter how self-righteously it's defended, the fact that med errors do happen--a lot--would seem to counter the opinion that they are avoidable.
Med errors occur (except, apparently, to a proud and rather self-righteous few--this said gently and most respectfully).
Nurses who made these errors used to be summarily scapegoated for all mistakes, lost their licenses, and were treated on an entirely individual basis. Unlike doctors, pharmacists, et al, who were allowed to continue to practice and for whom the hospitals would cover up.
A trend in med errors was noted and a system devised that countered the propensity for error with wonderful items like unit dosing and separation of similar medications, legible handwriting laws, and other helpful changes. Nurses ceased to be fired for med errors so frequently (we all know a couple of nurses who were fired for med errors).
IMHO, those are good changes, and they in no way absolve the nurse of the responsibility of the error. I believe that was one of your arguments against the systems error approach, stevierae, but regardless of which, the terms of nursing licenses are dictated by the laws of our state BONs, not by the system (or lack thereof) of the hospital we are employed by.
That said, I believe that some of us were more upset to realize that the person in this particular case was NOT licensed, and therefore, had LESS TO LOSE by their error.
It would be the hospital, not the worker, that would be sued in this instance, no?
The person might lose their job, and have to get counselling for sure, but unless the hospital changed their system of allowing unlicensed personnel to administer contrast, the potential for more patients to die under the same circumstances would remain.
Again, while I respect your position, I disagree with it, and hope you can see why I hold mine. If you think that I'm rude, I'm sorry, it's not meant to sound that way.
Stevierae - I just have to add that up until recently active duty military were not ALLOWED to sue for any damages. I had minor surgery while on active duty, ended up with peritonitis and was quite ill for quite some time. However, due to this clause, suing was not an option. In fact, in reviewing my medical records, including operative report, there is no mention of the error. I do respectfully disagree with you in that there were many, many erros in military medicine but due to the "no suits allowed" clause, they were not reported. I was active duty in the 70's also.
Stevierae, I don't think you've been rude. A little high and mighty on your high horse, but not rude. j/k
Magnesium is a bit more common on medical and cardiac floors, where it wouldn't be unusual that a patient in pain may also need a supplement. But you're right. First I would go the labs and see what the mag level is and why the patients getting it. We must critcally think through all our meds we are passing, know why they are getting it, the side effects, contraindications, reactions to other meds, etc. An awesome task. You know from your law experience that lawyers and the state boards of nursing aren't going to give a flip that "the doctor ordered it" or "I was too busy to look it up".
I still strongly suggest looking at process improvement when errors are made. Even though most errors are made by some negligence on the part of the error maker, I still say change the abbreviations, the color of the meds, whatever it takes to keep us silly humans in line, while we're waiting for that wonderful job and safe ratios. Some good improvements have been made from lessons learned.
While we in Florida have an advocacy group out there trying to get mandated safe staffing levels (doubtful with Mr. Bush as governor we can try), in the meantime I struggle with meds with my 8 patient load. But I readily accept my assignment every day and pray I don't make an error and if I do, I'll accept responsibility. I've learned the hard way, never let your guard down in nursing no matter how heavy the load.
p.s. California nurses aren't the only ones out there getting educated on current trends, changes, medications, treatments etc. That was a bit arrogant don't you think? (not a personal attack, because I respect you a lot, just your statement is arrogant, imo) :)
Oh my... how awful... In my 15 years as a NURSE, I have never ever seen a topical cleaning solution in a syringe form.... sure we have those cylindrical tubes with foan on the end that you break to activate ....but a injectable syringe??? that is just insane.... That poor woman and her family.... and the person who made the mistake....my heart certainly goes out to them....
First let me say that I have not found your posts to be rude Stevierae. I always enjoy a good debate, with people that are passionate about the subject and also knowledgable to some extent and willing to accept the opinions of others as well. Then debate topics and issues rather than go the personal attack route. I have not seen you go that route(until just these last couple of posts and in defense) but have seen many others in this thread take that tack and not even actually mention the issue but rather just show offense at your opinion. I have been able to disagree with you and keep it to the issue without it becoming a personal battle royal and I feel you have done so as well. Let me just add that you are also articulate and well informed.
Now back to the issue I continue to believe that this is a sad mistake, I have also to some extent changed my mind after reading the text offered by whoever posted the link with more info.
I am now wondering several things as well, I agree that the wording in the original article is inappropriate, the part about a leg vein and the medicine going to the leg. I however would almost be willing to chalk this up to a sloppy reporter not getting the facts straight. But now there are other discrepencies in the following reports, Ms. Mc Clanton(sp) called her sons two hours post op and told them something was very wrong, although the one report states she had a severe stroke at the end of the procedure. I was always very concerned with why the prep would even be around at the end of the procedure as it used pre-opening not, pre closing which for me also causes two more probelems, they stated that they were preparing to use it prior to closing and you don't actually close a groin sheath site you can use a closur-pad or and angioseal or like product but you would not clean the area prior to this and usually all they do is remove the sheath and hold direct pressure for 15-20/min. So in retrospect and with more information, I am now somewhat to the opinion that you are correct in your original assessment that too many things were fishy as it were. Possibly your experience in this area had awakened you to see these things a little clearer than some of us that do not have your experience and possibly many of us are simply putting ourselves in the shoes of a person making a fatal med error and feeling that we like that the facility seems to be protecting it's employee. I also find it somewhat controversial that a tech is sited as giving the injection and that makes me wonder if this isn't scapegoating to some extent by saying a tech did this a physician will remain free from lawsuit, and the facility is openly willing to take the brunt of the exposure(for a tech) which in my jaded mind seems too convienent.
Okay i just read the entire thread and I would have to opine that Stevie... You have in no way been rude....And I don't think others have been rude, just passionately expressing their opinion. You are most certainly entitled to your opinion and I find that your thoughts on this matter are very astute. You are one smart Cookie. That said, I would say that your statement of med errors not made in your corps days is perhaps YOUR PERCEPTION of the events in your life, but certainly not the reality.. People make mistakes, it happens. There are Many different perspectives on the issues and that's what makes this board so wonderful...EVERYONE benefits from the exchange of opinions and thoughts...
p.s. California nurses aren't the only ones out there getting educated on current trends, changes, medications, treatments etc. That was a bit arrogant don't you think? (not a personal attack, because I respect you a lot, just your statement is arrogant, imo) :)
LOL, Tweety, you know I didn't mean it that way--I was only speaking for myself and my CA colleagues, since that's where I practice, in contrast to the state in which I RESIDE, where CEs are not mandatory. Also, I was commenting on the fact that CA nurses were radical enough to actually take matters into their own hands and GET a safe staffing law passed, along with the help of CNA, the big and very powerful nurses' union--no small accomplishment! We didn't just sit around and complain about unsafe staffing--we wrote letters, went on strike when needed, met with legislators and spoke before the legislature. I am planning on addressing the OR state legislature soon, as part of the newly formed Patient Safety Commision, formed by attorneys here who were alarmed at unsafe staffing and other suboptimal patient care conditions, and I plan on rallying as many OR nurses as I know to join me--then maybe WE can be instrumental in getting a safe staffing law passed HERE.
I know nurses here (Oregon) who brag that they haven't taken a class or cracked a book or even a nursing journal to educate themselves on ANYTHING nursing related since they graduated from nursing school in the '80s, and that's sad. I am sure some of the Oregon nurses who post here know and work with people like that, too.
Of course, there are those, I am sure, who DO pay for their own CEs, even though they are not required--but they are mostly nurses, like me, who came from another state where they WERE required and, just out of habit and wanting to keep up, continued to take CE classes, and, if we happen to remember or keep receipts (I always forget) we can use them as a tax deduction.
I was in NO way insinuating that nurses from other states don't stay up on current trends or education--I know that in your state there are some cool classes offered--I think you guys need, in addition to medication classes, AIDS, hepatitic C and domestic abuse spotting and reporting classes, am I correct? I have seen those offered in catalogues like Anderson and they always say "satisfies FL requirements."
I would certainly think though that in states where CEs are NOT required--and not paid for by the employer--there is little motivation to get them, and that's probably natural.
Me, arrogant? :chuckle I am probably the most laid back person I know.
I just read this whole thread too - being another "Stevie" I thought to myself what the heck did I write in this thread that was offensive. :chuckle (actually I haven't written anything until now).
Stevierae - I found your input very insightful and agree with your perspective on med errors and not putting up with unsafe working conditions.
I also think that identifying anything that contribute to med errors in a non-punative way is a good thing too.
This whole conversation is very important and I have not found you to be arrogant at all. We do need to look at ourselves. To tell the truth, I haven't asked another nurse to check my insulin dose in ages. That is probably arrogant on my part. And something that I'm changing after reading this thread.
In the end, it is still the nurse's responsibility to administer meds in a safe manner no matter what the circumstances.
Stevierae - I do respectfully disagree with you in that there were many, many errors in military medicine but due to the "no suits allowed" clause, they were not reported. I was active duty in the 70's also.
Possibly true. PROBABLY true. I never really thought about med errors being made and not reported--it was just soooo drilled into us in corps school that we needed to always, always ALWAYS double check or even triple check our meds--ESPECIALLY insulin and heparin, with another person--that we always did so--at least the people I worked with did. So, if there were math errors on the first calculation (I am referring to when we had to calculate our dosages mathematically) it would SEEM that they'd be caught by the person doing the double checking--usually an RN, and Navy RNs were very highly educated and sophisticated--and thus the potential administration error caught and prevented.
However, I guess it's entirely possible that 2 people could make the same miscalculation and never even be aware of it--thus making a med error--and I guess it's entirely possible that there were corpsmen that never even bothered to have their calculations double checked, or those who blatantly covered up their med errors--i.e., charted tha tthey gave a med when they really did not--- and were lucky enough not to get caught. I guess I am naive enough to think that if I wouldn't lie, then neither would anyone else. I worked with a really good, conscientious group of people at each of my duty stations.
At our small Navy hospital in Rhode island, if indeed there was a med error committed that was reported and caused harm, you can bet the entire hospital would have known about it--even if the pending captain's mast would have been kept top secret, word would have leaked out from someone who worked in the captain's office--not to mention people would wonder why someone was now wearing one less stripe and not doing direct patient care anymore.
But, you are absolutely correct--just because none were ever reported doesn't mean, absolutely, that none occurred.
Even in the '80s and '90s, in civilian life, surgical complications (and perhaps med errors?) that caused no visible or obvious harm were seldom recorded on anything but an incident report, which was not discoverable. That deceitful atmosphere, which always bothered me, has fortunately changed, and things that were usually not disclosed to the patient (unless they suffered visible or otherwise obvious harm, and then there was no way around it) now are not only recorded in the permanent medical record, but are divulged immediately. It's simply the right thing to do.
Speaking of which, now I just read a little news article --the first I have seen about the Washington case--that says that a big picture fell off the wall, onto the head of the woman who died of the Chlorhexidine injection, while she was sitting in some waiting room at VM about a month before the Chlorhexidine incident. WTF?!!!
NOW VM is saying that, had it not been for that good fortune (the picture falling on her head and her subsequent CT scan,) she would never have known she had an aneurysm. I can't figure out why they are divulging this info--I mean, are they trying to suggest that, after all, the family should not be angry because, if not for VM causing her head trauma in the first place, she would have gone undiagnosed and probably died of a ruptured cerebral aneurysm? And perhaps the family should keep that in mind if they even THINK about suing? This whole thing is getting "curiouser and curiouser."
I also find it somewhat controversial that a tech is sited as giving the injection and that makes me wonder if this isn't scapegoating to some extent by saying a tech did this a physician will remain free from lawsuit, and the facility is openly willing to take the brunt of the exposure(for a tech) which in my jaded mind seems too convienent.
Exactly---seems to me that an interventional radiologist would be the one giving the contrast.....(or in this case, the Chlrohexidine...) NOT a tech....
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gwenith, BSN, RN
3,755 Posts
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