Not sure if anyone else has posted about this... Apparently a nurse administered epidural anesthesia intravenously, mistaking it for penicillin that was prescribed for the woman in labor. 
Nurse Drug Error Caused Teen's Death
State Report Also Says St. Mary's Must Improve Its Practices Or It Will Face Sanctions.
The Capital Times :: FRONT :: A1
Saturday, July 22, 2006
By Bill Novak The Capital Times
A registered nurse at St. Mary's Hospital in Madison made a fatal mistake by administering the wrong medication into 16-year-old Jasmine Gant, causing seizures and ultimately her death while giving birth to her son.
State and federal authorities are now warning the hospital to improve its practices or risk sanctions, including the revocation of its license.
An investigation that was made public Friday showed that Gant died after an epidural anesthetic was mistaken for a prescribed dose of penicillin and injected into her intravenously.
The epidural, meant to be inserted via a catheter into Gant's spine to ease her pain, instead entered her bloodstream at 11:45 a.m. July 5. She suffered seizures shortly afterward, and efforts to resuscitate her failed.
Gant was died at 12:20 p.m., according to hospital notes. Her son, Gregory, was delivered by Caesarian section, and Gant was pronounced dead at 1:43 p.m.
Dr. Frank Byrne, president of St. Mary's Hospital, issued a statement Friday that said the hospital "wishes to express our sincere apologies to Jasmine's family for this tragic error."
"Everyone at St. Mary's has been deeply saddened by Jasmine's death," he said, adding that the hospital offers its "profound sympathy."
Byrne said that "we hope to honor Jasmine's memory by making every conceivable effort to prevent such an error from ever recurring."
The registered nurse who administered the wrong medication was not identified in the state's report. She is on paid administrative leave, according to St. Mary's spokeswoman Sarah Carlson.
According to the state's investigation, which was conducted on July 12 and 13, the nurse "did not recall checking the medication prior to attaching it to the IV."
The penicillin bag had not been fitted with tubing to deliver it intravenously, while the epidural bag had tubing attached to it, investigators said.
Bar codes are used on patients' identification band as well as on medical packaging, the investigative report said. These codes -- called the bridge system at St. Mary's -- are supposed to ensure that the right medication is being given to the right patient. The codes are supposed to be scanned before medication is administered, but the nurse told investigators that she didn't use the bridge system for verification.
After Gant's death, the nurse was shown the epidural medication where the penicillin bag should have been.
St. Mary's reported the death under "caregiver error" rules, and released their statement Friday after being granted permission from Gant's family. Byrne said it was "a time of great sadness."
In the course of its investigation, the Bureau of Quality Assurance in the state's Department of Health and Family Services found three deficiencies in the hospital's nursing services and pharmaceutical services.
The deficiencies involved: failing to ensure care plans are established for patients in labor; failing to store all medications in locked areas; and failing to ensure policies and procedures were followed for safe administration of medications.
Stephanie Marquis, spokeswoman for the state Department of Health and Human Services said St. Mary's has 10 calendar days to submit a plan of correction for the three deficiencies found during the investigation.
The hospital also must have the violations corrected and be in compliance with state law within 60 days after the investigation was completed, so the hospital must be in full compliance by Sept. 11.
Failing to take these steps could lead to major sanctions, Marquis said. The state has the power to revoke the hospital's license to operate or suspend the hospital's ability to admit new patients.
St. Mary's could also face sanctions by the federal government since it accepts Medicare and Medicaid patients. Because of the incident, the hospital could have Medicare and Medicaid funding terminated if it does not respond to the problems cited in the investigation.
Byrne said St. Mary's is cooperating fully with local, state and federal agencies.
Marquis also told The Capital Times Friday night the incident has been reported to the state's Department of Regulation and Licensing because a nurse is involved.
Marquis wouldn't say if the district attorney's office could become involved in the case, which involves an ongoing investigation at several levels.
Nurse Drug Error Caused Teen's Death
State Report Also Says St. Mary's Must Improve Its Practices Or It Will Face Sanctions.
The Capital Times :: FRONT :: A1
Saturday, July 22, 2006
By Bill Novak The Capital Times
A registered nurse at St. Mary's Hospital in Madison made a fatal mistake by administering the wrong medication into 16-year-old Jasmine Gant, causing seizures and ultimately her death while giving birth to her son.
State and federal authorities are now warning the hospital to improve its practices or risk sanctions, including the revocation of its license.
An investigation that was made public Friday showed that Gant died after an epidural anesthetic was mistaken for a prescribed dose of penicillin and injected into her intravenously.
The epidural, meant to be inserted via a catheter into Gant's spine to ease her pain, instead entered her bloodstream at 11:45 a.m. July 5. She suffered seizures shortly afterward, and efforts to resuscitate her failed.
Gant was died at 12:20 p.m., according to hospital notes. Her son, Gregory, was delivered by Caesarian section, and Gant was pronounced dead at 1:43 p.m.
Dr. Frank Byrne, president of St. Mary's Hospital, issued a statement Friday that said the hospital "wishes to express our sincere apologies to Jasmine's family for this tragic error."
"Everyone at St. Mary's has been deeply saddened by Jasmine's death," he said, adding that the hospital offers its "profound sympathy."
Byrne said that "we hope to honor Jasmine's memory by making every conceivable effort to prevent such an error from ever recurring."
The registered nurse who administered the wrong medication was not identified in the state's report. She is on paid administrative leave, according to St. Mary's spokeswoman Sarah Carlson.
According to the state's investigation, which was conducted on July 12 and 13, the nurse "did not recall checking the medication prior to attaching it to the IV."
The penicillin bag had not been fitted with tubing to deliver it intravenously, while the epidural bag had tubing attached to it, investigators said.
Bar codes are used on patients' identification band as well as on medical packaging, the investigative report said. These codes -- called the bridge system at St. Mary's -- are supposed to ensure that the right medication is being given to the right patient. The codes are supposed to be scanned before medication is administered, but the nurse told investigators that she didn't use the bridge system for verification.
After Gant's death, the nurse was shown the epidural medication where the penicillin bag should have been.
St. Mary's reported the death under "caregiver error" rules, and released their statement Friday after being granted permission from Gant's family. Byrne said it was "a time of great sadness."
In the course of its investigation, the Bureau of Quality Assurance in the state's Department of Health and Family Services found three deficiencies in the hospital's nursing services and pharmaceutical services.
The deficiencies involved: failing to ensure care plans are established for patients in labor; failing to store all medications in locked areas; and failing to ensure policies and procedures were followed for safe administration of medications.
Stephanie Marquis, spokeswoman for the state Department of Health and Human Services said St. Mary's has 10 calendar days to submit a plan of correction for the three deficiencies found during the investigation.
The hospital also must have the violations corrected and be in compliance with state law within 60 days after the investigation was completed, so the hospital must be in full compliance by Sept. 11.
Failing to take these steps could lead to major sanctions, Marquis said. The state has the power to revoke the hospital's license to operate or suspend the hospital's ability to admit new patients.
St. Mary's could also face sanctions by the federal government since it accepts Medicare and Medicaid patients. Because of the incident, the hospital could have Medicare and Medicaid funding terminated if it does not respond to the problems cited in the investigation.
Byrne said St. Mary's is cooperating fully with local, state and federal agencies.
Marquis also told The Capital Times Friday night the incident has been reported to the state's Department of Regulation and Licensing because a nurse is involved.
Marquis wouldn't say if the district attorney's office could become involved in the case, which involves an ongoing investigation at several levels.
OMG! They didn't check to see what medication they put in her!
for that poor young mama. Did the baby die too?
