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Discussion Starter · #1 ·
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.
 

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OMG! They didn't check to see what medication they put in her!
 

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Happens waaay too frequently. People think they are safe when they go into the hospital. What everyone needs for anything - big or little - when dealing with the medical system is an advocate, someone there who loves them and will ask questions.

What a mess.

Human error is going to happen. They can't eliminate it.
 

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for that poor young mama. Did the baby die too?

Saddest is realizing that, if she was having a drug-free childbirth, this never could have happened.
 

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The baby is fine, being raised by his grandparents now, I believe.
 

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Under safety standards, nothing except IVs are supposed to be fitted with IV-compatible hubs. Yes, the nurse should have checked the med, but the hospital also should have used safety checks. Epidurals are narcotics anyway; they're supposed to be controlled-access. I've never worked in a hospital that had them freely available the way penicillin is, nor one that used a system with the same tubing as an IV. It's not just a one-person error (though there was a nursing error); it's a systems failure. And I will bet my right boob that nurse had too many patients. Understaffing raises your risk of death in the hospital more than any other factor.
 

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Discussion Starter · #8 ·
Quote:

Originally Posted by maxmama
Under safety standards, nothing except IVs are supposed to be fitted with IV-compatible hubs. Yes, the nurse should have checked the med, but the hospital also should have used safety checks. Epidurals are narcotics anyway; they're supposed to be controlled-access. I've never worked in a hospital that had them freely available the way penicillin is, nor one that used a system with the same tubing as an IV. It's not just a one-person error (though there was a nursing error); it's a systems failure. And I will bet my right boob that nurse had too many patients. Understaffing raises your risk of death in the hospital more than any other factor.
The hospital uses bar codes on the patient ID bracelets and the medications the nurse, however failed to scan the bar codes. Not having controlled access was a failure of the hospital but not scanning was clearly the nurses failure.

According to the hospital they are fully staffed, no nursing shortages in the hospital or in this area in general.
 

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Quote:

Originally Posted by mamato2boys
According to the hospital they are fully staffed, no nursing shortages in the hospital or in this area in general.
Ha. No hospital will actually admit - especially under these circumstances - that it was improperly staffed. And most of them aren't.

Most hospitals who want to make this claim - mine did - will adjust the number of FTEs for their departments as being X nurses on for Y hours and say that that's their staffing ratio...and even if the number of nurses on should be X+3 for Y hours, if the hospital only has X, then they will claim that that is the number that they *need*. It's utter %$#.

I can't imagine being the nurse in this case. I can't imagine living with that. Blessings for both the nurse and the family involved.
 

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How tragic for this woman's family. However, I find it optimistic that the hospital clearly admitted exactly what their (and the nurses) error was, and is trying to cooperate to put better, safer measures in place to prevent the mistake again.

What disgusts me a lot more is when a staff member, or hospital make a severe mistake like this one, but spend all their time buring the error, covering it up with innaccurate records, or force the family to sue in order to get the information about what really happened to their loved one. It seems this this, not honesty, is the norm in insurance driven societies.
 

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Quote:

Originally Posted by mamato2boys
The hospital uses bar codes on the patient ID bracelets and the medications the nurse, however failed to scan the bar codes. Not having controlled access was a failure of the hospital but not scanning was clearly the nurses failure.

According to the hospital they are fully staffed, no nursing shortages in the hospital or in this area in general.
Regardless of bar code use, IV meds are only supposed to be compatible with IV tubing. Our epidural bags, for example, use entirely different tubing that isn't compatible with IV hubs.

And I agree with the other poster that hospitals manipulate their FTE/patient numbers to look better-staffed. There aren't ratio minimums in most states, and what matters is nurse-patient ratio on the floor in that particular unit. AWHONN standards are for one-to-one nursing in active labor. Most hospitals don't meet this.
 

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Quote:

Originally Posted by maxmama
Regardless of bar code use, IV meds are only supposed to be compatible with IV tubing. Our epidural bags, for example, use entirely different tubing that isn't compatible with IV hubs.

Our hospital does the same thing. I simply couldn't "spike" IV tubing into an epidural bag.

Thats not to say that other medication errors don't happen, just not that one. And our epidurals are never with the other medications either. They are controlled and must be ordered one at a time for each patient. I have to personally go to the pharmacy to get it, or they send it via "secure" tube (like at a bank drive thru).

How incredibly awful for that young patient. I don't know what I'd do if i ever made an error of that magnitude.
 

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Two things I have heard:

-the epidural medication was in the room because the girl was afraid and the nurse brought it in to explain how the process of getting the medication works.

-after it came to light about what happened the nurse was admitted to a hospital psychiatric unit on suicide precautions.
 

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Quote:

Originally Posted by maxmama
Under safety standards, nothing except IVs are supposed to be fitted with IV-compatible hubs. Yes, the nurse should have checked the med, but the hospital also should have used safety checks. Epidurals are narcotics anyway; they're supposed to be controlled-access. I've never worked in a hospital that had them freely available the way penicillin is, nor one that used a system with the same tubing as an IV. It's not just a one-person error (though there was a nursing error); it's a systems failure. And I will bet my right boob that nurse had too many patients. Understaffing raises your risk of death in the hospital more than any other factor.
Your are right about the controlled access, but the way it works here is you have to get the medication from the computer runned med system but you can get it out and it might not be given right away, you know, set down on a counter while you hurry and complete something else first. You hardly ever get to hang the med the minute after you get it out without being interupted by something on the way, at least that's how it happens to me all the time. Why you have to recheck what you're giving immediately before you do it.
 

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Quote:

Originally Posted by mara
Your are right about the controlled access, but the way it works here is you have to get the medication from the computer runned med system but you can get it out and it might not be given right away, you know, set down on a counter while you hurry and complete something else first. You hardly ever get to hang the med the minute after you get it out without being interupted by something on the way, at least that's how it happens to me all the time. Why you have to recheck what you're giving immediately before you do it.
Right, but my point was that signing out the bag is a different process from grabbing a bag of penicillin from the fridge. We're busy, but we have staffing ratios in our new contract and it's made a huge difference in doing my job. I can finish a task! It's incredible!
 

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Wow. She's dead because she did what she was "supposed to".
She went to the hospital and got an epidural.

And people think WE are crazy?
 

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Discussion Starter · #18 ·
Quote:

Originally Posted by bobandjess99
Wow. She's dead because she did what she was "supposed to".
She went to the hospital and got an epidural.

And people think WE are crazy?


Maybe the bigger issue with this case should be the problem with the birth culture in the US. Nurses wouldn't be so busy and working with more patients than they are able to if our culture didn't believe that it was necessary for a healthy woman with an healthy pregnancy to birth in a hospital. Epidural medication wouldn't have been in her room if our culture didn't see labor pains as unnatural occurances that need to be managed and taken away with medication. If the only woman that birthed in hospitals under the care of OB's and nurses were women that actually needed medical attention in labor and birth the one to one ratio would be met and all women and children; birthing at home and at hospitals would be safer! This is what we should be working to achieve, this is what we all should be fighting for!!!
 

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Quote:

Originally Posted by maxmama
but we have staffing ratios in our new contract and it's made a huge difference in doing my job. I can finish a task! It's incredible!
You are so lucky. Unionized?
 
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