2007 Medication Error Stories
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& Hosts Contact CPR For Colorado mom, story of daughter's hospital death is key to others' safety By John Daley Feb 17,
Fatal Medication Error Stories
2015 Audio: CPR's John Daley reports on on patient safety advocate Carole Hemmelgarn Alyssa Hemmelgarn reading a book. (Photo: Courtesy of Hemmelgarn family) Carole Hemmelgarn, of Highlands Ranch, is on a mission to help medical professionals avoid errors. She's had first
Medication Error Stories 2012
hand experience of how, she says, the healthcare system failed her family and ultimately her daughter. “I had a 9-year-old daughter, named Alyssa, and she was diagnosed with leukemia on a Monday and she died 10 days later,” said Hemmelgarn. From skiing to the hospital While skiing one day in 2007, Alyssa seemed lethargic. She had swollen glands and a cold sore that wouldn’t heal. Hemmelgarn thought she had mono. But soon, Alyssa was admitted to a medication error stories 2013 Denver-area hospital, diagnosed with leukemia. A week later, she was having her best day since being admitted. They walked around the hospital, watched a movie, but then things took a turn. “She started failing probably about six o’clock," said Hemmelgarn. "When I say failing, her belly was hurting, her behaviors were changing. She wasn’t comfortable.” In her chart days earlier, one of her providers had noted Alyssa seemed “anxious.” Based on that, a doctor in training prescribed her the anti-anxiety drug Ativan. The hours passed. Alyssa's blood pressure started to drop and her pulse raced. “She was failing in so many other ways," Hemmelgarn said. "The medication wasn’t helping at all because that's not what the issue was.” Alyssa Hemmelgarn in her fourth grade picture. (Photo: Courtesy of Hemmelgarn family) By morning, the situation was dire. Alyssa’s Dad grabbed his daughter's foot. It was ice cold. Hemmelgarn yelled for someone to do something. Alyssa was rushed to an intensive care unit, then into surgery. “She was brought back to us and we were told that she would not live," said Hemmelgarn. "We had to make the decision to let her go.” Hemmelgarn said Alyssa had a severe hospital-acquired infection, known as C. diff. She calls it a classic case of “failure to rescue.” Those caring for Alyssa failed to spot critical lab results and respond appropriately and quickly enough.
about Medical Errors Brother bled to death from central line medical error On June 9, 2008, my brother, Kenneth Novak died medication error stories 2014 due to the terrible mistake of two anesthesiologists at a hospital in Fort pharmacy medication error stories Lauderdale, FL. While central lines were being placed into his internal jugular vein to prepare for a liver transplant, the medication error articles catheter/needle was advanced too far, perforating both the jugular and right subclavian artery. My brother bled to death. Although these doctors admit to making a terrible mistake, they are not being held http://www.cpr.org/news/story/colorado-mom-story-daughters-hospital-death-key-others-safety accountable in any way. The hospital offered to pay my Mother $18,000.00, but only in exchange for her not to pursue complaints on the hospital or any of the physician’s involved. My mother refused to sign off her son’s life for $18,000.00 and completed the formal complaints to the Florida Department of Health. After each investigation on the physician’s involved, The Department of Health sent my http://safepatientproject.org/sys-medical_errors.html mother back a letter simply stating that "there is no probable cause," and thanking her for her attention to this matter. Thanking her for her attention to this matter? Oh my goodness, this was her son. These doctors are covered under Florida statutes that prevent us from gaining any real information. My family is devastated...the Department of Health would not answer one question we had regarding my brother's death because of this Florida law. What does a family do? No answers, no reasons for this tragedy. My mother is not suing; she wants accountability for her son's death and does not want this to happen to anyone else. One ironic point here is that I found that one of the anesthesiologists did not complete his 2 hours of continuing education on "How to Prevent Medical Errors." He simply paid a $589.00 fee and that was it. Why wouldn’t these physicians receive further training or a root cause investigation on how/why this happened or how to prevent it from happening again? What happens when they do the same thing to the next patient? We realize there are risks in surgery, but there must be
drug mishap Dennis Quaid and Kimberly Buffington Associated Press Dennis Quaid and wife Kimberly arrive at a film premiere in 2006. The couple's newborn twins were http://www.latimes.com/entertainment/gossip/la-me-quaid5dec05-story.html given an accidental overdose of the blood thinner heparin. Dennis Quaid and http://asq.org/qualitynews/qnt/execute/displaySetup?newsID=1056 wife Kimberly arrive at a film premiere in 2006. The couple's newborn twins were given an accidental overdose of the blood thinner heparin. (Associated Press) Charles OrnsteinLos Angeles Times Staff Writer Actor Dennis Quaid and wife Kimberly sued a leading blood-thinner manufacturer Tuesday, saying the labeling medication error and design of the product led to a massive overdose of their newborn twins last month at Cedars-Sinai Medical Center.The Quaids' babies, Thomas Boone and Zoe Grace, twice were given 1,000 times the intended dosage of heparin on Nov. 18 at the Los Angeles hospital. At 11:30 a.m. and again at 5:30 p.m., nurses mistakenly administered heparin with a concentration of 10,000 medication error stories units per milliliter instead of 10 units per milliliter, the family's attorney said. Another child also was given the wrong dose of the medication, often used as a flush to prevent blood clots around intravenous catheter sites.All three children have since been released from the hospital, which said they suffered no adverse health effects. Detailing the incidents for the first time Tuesday, Cedars-Sinai cited at least three separate safety lapses that led to the overdoses.In a prepared statement, the hospital said a pharmacy technician took the heparin from the pharmacy's supply without having a second technician verify the drug's concentration, as hospital policy requires. Then, when the heparin was delivered to a satellite pharmacy that serves the pediatrics unit, a different technician there did not verify the concentration, as required. Finally, the nurses who administered the heparin to the patients violated policy by neglecting to verify that it was the correct medication and dose beforehand, the hospital said.The staffers involved were relieved of duty during the investigation and "appropriate disciplinary actions are being taken," the hospital said.Heparin is one of the most frequently used -- and misused -- drugs in
serve three years of probation after pleading no contest to reduced charges, but medical and nursing societies are concerned about the effect the case might have in future medical error situations. Julie Thao was a nurse at St. Mary's Hospital in Madison, WI, in the summer of 2006 when 16-year-old Jasmine Gant was admitted to give birth. Through a series of actions, shortcuts, and omissions, all of which Thao accepted responsibility for at her sentencing in December, she mistakenly gave Gant an epidural anesthetic (Buvipacaine) intravenously. Gant was supposed to receive an IV antibiotic for a strep infection. Within minutes of receiving the epidural IV, Gant suffered seizures and died. Her child, a boy, was delivered by emergency Caesarean section and survived. According to the investigator's report, Thao: improperly removed the epidural bag from a locked storage system without authorization or permission; did not scan the bar code on the epidural bag, which would have told her it was the wrong drug; ignored a bright pink warning label on the bag that stated the drug was for epidural administration only; and . disregarded St. Mary's "5 rights" rule for drug administration — right patient, right route, right medication, right dose, and right time. News reports quoted Thao saying, "This was my mistake, everything was my fault" at the time of her plea. She will serve three years on probation, her license has been suspended for nine months, and should she return to nursing (she was fired from St. Mary's), she will face close scrutiny of her hours and work performance. Despite the action by the state nursing board in chastising Thao and suspending her license, medical and nursing associations have been almost unanimous in protesting the felony criminal charges in a case of a mistake. "It is imperative that all health care professionals do everything possible to ensure that medical errors do not happen. Patient safety is critical," according to Ruth Heitz, JD, general counsel to the Wisconsin Medical Society. "But to use the criminal justice system in this unprecedented manner to prosecute acts of unintentiona