21A Medication Errors
Although medication errors are already cited in Europe as the fifth most common cause of patient death in hospitals (Commission of the European Communities, 2008), the number of adverse drug events is anticipated to grow due to the advent of new medicines, the aging population, and expansion of insurance coverage (CDC, 2010). In the US, adverse drug events constitute one third of all adverse events in hospitals (Department of Health and Human Services, 2014).
Our APSS outline actionable steps healthcare organizations should take to successfully implement and sustain behavior change for high reliability, shared understanding, thorough communication, and meaningful person-centered care across the organization.
Actionable steps include:
- Executive Summary Checklist
- Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
- Performance improvement plan to follow if improvements are necessary
- Clinical workflow for preoccupation with workflow for areas of improvement
- How to educate patients and family members about the significance of their role throughout the continuum
- Guidance on how to measure outcomes
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Patient Stories
John Kinder
As told by John’s wife, Kathy Kinder
I’m a registered nurse, and have worked in healthcare for almost 30 years. In 2011, my husband had a bout of diverticulitis. Subsequently, the surgeon recommended an elective laparoscopic colon resection. So, in 2012, he went in for this simple procedure.
When he arrived at the floor, I was told that for the most part it went well. Although, he did have lap surgery, they also decided to give him a temporary ileostomy. However, when I arrived to see him around 4pm post-operative, he was sweating, pale, very little urine output in his foley and his abdomen looked like he was nine months pregnant. I called his nurse into the room, who also was a friend of mine. She agreed that something was wrong. She called the doctor and started a second IV. The doctor came and said he was dehydrated. I argued that he looked like he was internally bleeding. He said he was fine, but agreed to order labs.
I asked also for an X-ray or CT scan and was told that was unnecessary. Labs demonstrated that there was a blood loss, and his potassium was elevated to about 7. (Elevated potassium can be a symptom of internal bleeding). The MD came back, and ordered a type and cross and transfusion of two units, plus a bolus, because his blood pressure was under 90 systolic. He still refused an X-ray. He just said well maybe he is having some sepsis, and I don’t believe he is bleeding, “I believe it’s just blood loss from the surgery”. He said he believed the potassium was in error, it wasn’t and he was give d50 and insulin to bring it down.
The hours ticked by, and my husband continued to deteriorate, and around 11pm, they transferred him to ICU. I went home, because he was in the hands of the ICU intensivist, and we 5 kids, four of whom were still in school. Around 1am, I got an urgent call from the ICU intensivist that he had ordered a CAT scan. My husband’s belly had an estimated 2 liters of blood in it, and they were calling in a trauma surgeon. His hemoglobin was about 5 and mass transfusion protocol was initiated. When they opened him, my husband was full of blood. The trauma surgeon was able Patient Safety Movement Foundation | patientsafetymovement.org to stop the bleeding, but unable to close his belly. He was brought back to the ICU intubated, and belly packed. He went back to the OR after the internal swelling went down, and was closed. It was a year-long recovery. This was due to failure to rescue. If I had as a family member called a rapid response at 5pm, this could have been avoided. My husband took a long time to recover. My husband almost died.
I’m thankful that he is alive, but his long recovery could have been avoided if he had had the proper interventions early in the evening. After the event, people couldn’t believe that this could happen to a nurse’s husband. IF this could happen to my husband, it could happen to anyone.
Patient Stories
Abdi Towfigh
We lost Abdi when he was only 30 years old. He personified all the strengths you would expect: strong, fit, confident, articulate, intelligent and compassionate. His softer qualities impressed everyone the most: warmth, humility, kindness, consideration and appreciation. We lost him to two medical mistakes while he was hospitalized, which were preventable by all means. Both mistakes arose from reading another patient’s lab results and another patient’s CT scan results which resulted in him being injected with the wrong medication and undergoing an unnecessary surgery which took his life. Although nothing can undo the loss we all experience from losing a loved one, especially due to a preventable mistake, but sharing this pain can empower others to be more proactive and take a more active role in their healthcare and encourage a sense of excellence in a partnership between healthcare receivers and healthcare providers. Excellence is the result of caring more than others think is wise, risking more than others think is safe, dreaming more than others think is practical, and expecting more than others think is possible. It is the commitment to high quality performance that produces outstanding results of lasting value.
Patient Stories
Carol Amundson
As told by Carol’s daughter, April Lindquist, on behalf of her father and siblings
Our mother, Carol, passed away on November 9, 2018, the day before her 77th birthday, from multi-organ failure, due to a very toxic antiarrhythmic drug that never should have been prescribed to her.
After her passing, my father and I requested her medical records from 2005-2018; which represented the 13 year timeframe her cardiologist kept her on the toxic drug. It was our goal to find out where the breakdown in her medical care occurred. Over the course of four months of reviewing 1,800 pages of documents from the same hospital and clinic system, it became evident to our family what happened. It is now our goal to inform others of her story.
In February 2005, Carol was diagnosed with new on-set paroxysmal atrial fibrillation. The first drug, Sotalol, did not agree with her, so the cardiologist team switched her to Pacerone; which is also referred to as Amiodarone or Cordardone. In 1985, the FDA approved the use of Pacerone (Amiodarone) for life-threatening, recurrent ventricular tachycardia and ventricular fibrillation, not for mild to moderate paroxysmal atrial fibrillation, due to the toxic, dangerous side effects of the drug. Before 2005, she had a known allergy to iodine, and this was listed in all of her medical records. Yet, her doctors ignored or never took notice that iodine is 37% the molecular weight of the drug, and Carol was allergic to it. In March 2015, and maybe her doctors were concerned about liability, removed iodine/iodides from her list of allergens. At this point, she had been taking Pacerone (Amiodarone) for 10 years.
Our mother had numerous side effects over the 13 years while on Pacerone, which added to her list of doctors, added to her list of diagnostic procedures, and added to her list of prescribed medications, while compounding her symptoms due to interactions. It is difficult to cover all of what she went through, yet it is important to know some of her experiences to understand the side effects of this dangerous drug, and what the doctors could have done differently to save her life.
In July 2010, a CT Urogram found increased liver attenuation at 95. The normal range is Hounsfield Unit 55-65. Here was an opportunity for the urologist to investigate what was causing damage to her liver. Instead, he neglected to share this discovery with the patient and other members of her treatment team. All follow-up office notes mention simple renal cysts, and the increase in liver attenuation was omitted.
In 2008, our mother’s hands began to mildly shake. By 2010, her head also developed a tremor. Her hands shook so severely in 2018, that we purchased adaptive utensils with a rubber grip so she could feed herself. In the pharmaceutical company Upsher-Smith Laboratories’ 26 pages of information on Pacerone, tremors are a side effect of the drug and referred to as Parkinsonian symptoms. In October 2018, her cardiologist referred her to a neurologist to test for Parkinson’s disease, and a brain MRI was completed. The doctor prescribed Primidone (Mysoline), a seizure medication, before he had the MRI results. No patient with kidney disease should be prescribed this drug, and Carol had Stage 3 Kidney Disease. The neurologist was negligent in not reviewing her past and current lab work which would have verified her kidney and liver damage. Four days before Carol passed away, and after days of IV fluid in the Intensive Care Unit, the toxicity of the medications began to lessen, and her hands were calm.
Her thyroid function (TSH) was tested from 2005-2011 by her primary physician, and after 2012, her cardiologist began testing it annually knowing that Pacerone could cause hypothyroidism. In May 2011, with this new diagnosis, her cardiologist did not stop Pacerone, nor was thyroid medication prescribed.
As Carol became older and her liver and kidneys had a harder time filtering the side effects of her medications, the doctors’ office notes became briefer and showed less involvement in her care. Her cardiologist and her primary physician were referred to as her Care Team; yet, both doctors created anxiety for the unhealthy, cardiac patient due to their inability to consult with one another about the best course for her care. Her primary physician noted Carol’s anxiety about her health, and anti-anxiety medication or sometimes pain medication was ordered to placate the patient.
The lab work reviewed in July 2017 stands out as the month when the dysfunction of her Care Team is most baffling. The cardiologist ordered lab work to check her kidney function, liver function, cholesterol levels and thyroid function. Cholesterol levels came back normal. Kidneys: Stage 3 Kidney Disease; Liver: Abnormal; and elevated thyroid. The next office visit on October 11, 2017, makes no reference to reviewing the labs ordered in July. Also, on July 20th, 10 days after her abnormal lab results, Carol sees her primary physician for a Medicare Wellness visit. There is no mention of the doctor reviewing past lab work to determine the need for new follow-up lab work.
In the summer of 2018, Carol had a cough that would not go away and she became progressively more unsteady on her feet. A chest x-ray discovered pleural effusion. At this point, the heart was stable; yet no further tests were done to determine why fluid continued to build up around the right lung.
On October 24, 2018, our mother saw her cardiologist for a follow-up office visit. She had lost 17 pounds in three weeks from lack of appetite and her gait had changed. On this date, our father asked the doctor to stop the Pacerone because of her hypothyroidism. The doctor agreed and then put her on the thyroid medication Levothyroxine. This was the first thyroid medication ever prescribed to her. The doctor should have admitted her into the hospital on this day with a blood pressure of 104/50, pulse of 52, and weight loss. Instead he sent her home. The following day our father took her to the Emergency Room where she was admitted into the hospital. ER ordered tests and discovered portal vein occlusion. The portal vein brings blood to the liver from the intestines, but it was blocked. In addition, her CT (non-contrast) test found non-alcoholic hepatic cirrhosis, due to the occlusion, plus moderate ascites from the fluid buildup in her abdomen, which explained her lack of appetite.
During her hospitalization, our father and her four children, made sure that one of us stayed with her round-the-clock. Our mother was confused and agitated on one of the evenings I slept overnight with her. She tried to pull herself over to one side of the bed to use the bedside commode. To my horror, the bed’s guard rail was down, and I reassured her that she had a urinary catheter. I pushed the call button for help, and no one came until I called out loud for help. The next day our nurse sister arrived from out-of-town and asked the ICU nurse what Carol’s ammonia level was since she had a hard time answering questions and sipping water from a cup? The nurse said it had not been tested. She had a severe urinary tract infection, and the ammonia test should have been normal protocol. With medication, the elevated ammonia level went down and our mother was able to have short, memorable conversations with us, along with eating food and drinking liquids.
Her liver continued to deteriorate, and then the kidneys and then her heart. Her last few days were spent in Comfort Care surrounded by her family.
Pacerone has a half-life after stopping the drug. It can stay active for up to 58 days in the body. If this drug is stopped and another anti-arrhythmia drug is prescribed, it is equivalent to taking two drugs, along with all its side effects. On the seventh day of our mother’s hospitalization, we requested from the cardiologist a Pacerone (Amiodarone) toxicity test. We wished we had requested this test on the day she entered the ER. Due to two weeks of IV fluids, the Amiodarone and Desethylamiodarone levels noted the drug still in her system, but at the lower range. The hospital sent her blood to a laboratory in Ohio. Carol was the first patient the ICU nurse ever remembered being checked for Pacerone (Amiodarone) toxicity. It was a test our mother’s oldest granddaughter discovered through the FDA website.
When our mother passed away on Friday, November 9, 2018, the funeral home had to follow up with the hospital on November 23 because they had not received the death certificate from them. The funeral home finally signed it on November 26. From our prospective, this delay from the hospital in filling out the death certificate was a red flag. Sure enough! What the hospital neglected to include on the death certificate were portal vein occlusion and liver failure.
We have learned as a family that requesting our medical records and reviewing them is crucial to getting answers to unanswered questions. Know the side effects of medications and its interactions with other medications to avoid undergoing unnecessary tests. Some doctors will prescribe additional tests and procedures that look good on paper, and that is all it is, it’s on their computer, it’s on our mother’s medical records… it’s called defensive medicine to protect against being sued. We feel defensive medicine was also evident in the cardiologist’s passiveness in allowing our mother to suffer through 13 years of taking Pacerone until our father requested it to be stopped.
Also, a family member or friend should accompany the patient to an office visit to take notes or ask questions. Our mother’s elevated ammonia level, from a urinary tract infection, is a good example of how it clouds a person’s ability to understand and retain information from their doctor.
In the State of Wisconsin, a spouse or child of a parent under the age of 18 can sue for medical malpractice caused within three years from the date of death. It means all our mother’s documentation from 2005 to 2015 would not be allowed in as evidence, only 2016 to 2018. The cards are stacked up against the patient’s family with a case that can last from 2-3 years.
Patient Stories
Josh Barron
As told by Josh’s father, Ridley Barron
It only took a matter of moments for my world to fall part apart that Spring day. We were just a few minutes from our house as we returned from a family vacation when a driver raced through a stop sign and crashed into our vehicle. My wife of twelve years was killed instantly. EMTs informed me that day that I had watched as Sarah took her very last breath. At the same time, my seventeen-month-old son, Josh, had his seat belt snap and was ejected from our minivan as it tumbled down the highway after impact. Volunteers who arrived on the scene found Josh strapped in his car seat about 50 feet away from where our van had come to a stop.
Josh was taken to our local hospital in Southwest Georgia and moved from there, via a helicopter, to a larger hospital in Savannah, Georgia. For the next four days, our family would watch and pray for his continued recovery as we looked to move beyond the loss of his mother, Sarah. On day four his doctor informed me that Josh had a severe head injury but had continued to show steady improvement throughout his time in their care. He even hoped that Josh would improve enough to be a part of the upcoming trip to Middle Tennessee for the burial of his mother. His nine-year-old brother, Harrison, and his six-year-old sister, Abby, would pray each night that their little brother was safe and that he would soon be well enough to rejoin us.
So, it was with great shock that I received that phone call on the morning of day five. Doctors were asking that my family drop everything and get to the hospital as quickly as we possibly could. For us, that would be a 2-1/2-hour trip that would seem like forever. Upon arrival, we were greeted by doctors and administrators who asked us to meet with them in a conference room before they would allow us to go back to Josh’s room. It was in that conference room that the crumbling of my neat little world would reach its pinnacle. I was informed that a pharmacist’s error had resulted in a medication mistake. My son had received five times the amount of phenytoin needed for head seizures that he was having. Five times! I was lead into the room where I watched him die that day. I looked on as doctors made one last attempt to keep him alive but to no avail.
I decided two things that day. My son’s death would not be in vain; God would enable me to do something to bring good from the loss of my two family members. And I would do whatever I could with my story to help keep others from experiencing the needless pain I experienced that day. Mistakes happen. I get that. Health care workers are human. But mistakes don’t have to touch our loved ones. We must do everything we can to make sure that every preventable error becomes a distant memory. Every life matters; every half-second counts!
Patient Stories
Candace Downing
As told by Candace’s mother, Mathy Downing
Candace’s story is a horrific reminder of the damage medical error can cause.
At eleven years of age, Candace was prescribed an antidepressant, not for depression, but for test anxiety at school. After several months with no noticeable change, the dose was doubled. Candace eventually had a negative reaction to the medication, after being told that she could take an extra pill at night if she was nervous about school the following day.
The adverse reaction sent her to the hospital for monitoring, where instead, she was immediately administered not one, but two sedatives, which never should be given in combination with an antidepressant. Not only that, but the medication was doubled, given intravenously at twice the dosage one would give a 67-pound child.
The result was that Candace began having severe hallucinations, her heart rate doubled, her blood pressure skyrocketed, and she began running a fever. Then two days after being admitted to the PICU, she was given four times the amount of the antidepressant that sent her to the hospital in the first place, while I was informed that the blue pills she was given were Tylenol. Not only did I recognize the pills as antidepressants, our itemized bill validated what I witnessed. She was released two days later, still not eating or sleeping, with flu-like symptoms, and ebbing and flowing hallucinations.
Three days later, while in a drug-induced psychotic state, Candace hanged herself in her room, with no awareness of her actions. While I am glad she did not “suffer,” nothing can take away our needless emotional pain and suffering. Nothing can bring her back.
Patient Stories
Daniel Stratman
As told by Daniel's mother, Sue Stratman
On July 10, 1996, we took our precious 11-year old son to the Children’s Hospital for what was to be a routine inguinal hernia surgery. Daniel was no stranger to Children’s, having undergone three open heart surgeries there over the course of his short life. Those surgeries went textbook; however, this one would prove to be our worst nightmare.
During surgery, the attending anesthesiologist made not one, but several mistakes, we would later find out. First of all, she set the anesthetic too high for too long (almost as if Daniel were having another open heart procedure). Then, while she placed a blood pressure cuff on Daniel’s arm, she never reset the blood pressure machine to read it. (As we understood it, normal surgery protocol calls for a blood pressure reading every 2-3 minutes; Daniel’s machine was never reset to give out those numbers.) And then, she left the room, leaving a nurse anesthetist student in charge.
Eleven minutes into the surgery, the surgeon noticed things didn’t look right. Upon questioning the student as to Daniel’s status, the student realized the blood pressure numbers had not changed during those 11 minutes, and he hit the “reset” button. Daniel’s blood pressure was 34/13. Immediately he coded, and even though the “crash team” got his heart going again, the damage to his brain due to a lack of oxygen was significant and global…and our precious, active, energetic little boy was given back to us severely brain damaged.
Today, as a grown man, Daniel has extremely limited vision, speech, and motor skills. He walks only with a great deal of assistance and cannot take care of his needs by himself at all. He requires 24-hour assistance.
Patient Stories
Sabina Paradi
As told by Sabina's mother, Bodo Paradi
I would like to introduce my daughter Sabina Paradi.
She was a dietetic fellow at Columbia University, New York Hospital, in 2007 when she sustained traumatic brain injury after being struck by a truck in New York’s Lower West Side on the way from a play.
The system worked perfectly when she was assisted immediately by a passing nurse. In minutes she was dispatched via ambulance by a fine paramedical team and was brought for evaluation in the hospital.
This is where the system broke down. The immediate reaction by the team was to attempt to relieve acute elevated intracerebral pressure. The method chosen, hemicraniectomy, and the anesthetic (propofol) were both inappropriate to her care. Hemicraniectomy has been shown in a later study to be inappropriate in most cases. Propofol has been banned by the FDA in the treatment of pediatric traumatic brain injury patients because of various complications. My daughter was very slight of build, under 100 lbs, easily smaller than many pediatric cases. She was also athletic, which may have increased the tendency for higher intracerebral pressure. She had been ill for over a week, having contracted a resistant infection from one of her patients, and was taking antibiotics.
How would systems improvement have helped at this stage? Her condition should have been evaluated by a higher level of expertise, and used tools like teleconferencing and remote medicine to get the opinion of a nationwide team of experts. The hospital throughout her care lacked access to medical expertise other than what appeared to be a very overworked neurosurgeon. Traumatic brain injury cases in the first hours require extraordinary care in their evaluation.
What happened next? What happened next, I believe, is responsible for her death. She contracted a resistant pneumonia which was identified with her respirator. Complicating everything was that she was taking antibiotics, and therefore immunosuppressed; she had a head injury and was therefore immunosuppressed; she sustained extensive neurosurgery and was therefore immunosuppressed; and she was sedated and therefore immunosuppressed. The infections deepened her coma, along with the sedation.
Risking surgery and sedation in her case was very much contraindicated. There were and are many alternate protocols for handling cases like hers. Greater knowledge and the use of artificial intelligence might have led to an entirely different treatment regime. Other items needed were immediately accessible MRI, preferably state of the art; real-time polymerase chain reaction tests for the detection of microbial infections, in particular fungal infections which seem to plague the immunosuppressed; and a modern neurological intensive care facility. The facility at my daughter’s hospital had a ward shared among four neurologically impaired patients, all quite likely immunosuppressed.
In the end, what killed my daughter was a complete lack of knowledge of her condition which instrumentation and broader, specialized knowledge would have alleviated. Facilities like the US military traumatic brain injury facility at Ramstein, Germany, are more appropriate to the treatment of moderate to severe traumatic brain injury than hospital emergency rooms. It is my view that all such patients should be evacuated to very large specialty hospitals that treat only severe neurological conditions such as stroke, TBI, encephalitis, and the like. Air transport systems and stabilization protocols need to follow the military model.
Patient Stories
Holly Patterson
As told by Holly’s father, Monty L. Patterson
Holly Patterson died three weeks after her 18th birthday. Healthy and beautiful, this young native of the San Francisco bay area had her whole life in front of her.
Her story begins in 2003 when she entered a clinic with her boyfriend to terminate her seven-week-old pregnancy with the two-drug medical abortion regimen of mifepristone (commonly known as the Abortion Pill or RU-486) and misoprostol. (In 2000, the FDA approved a specific mifepristone medical abortion regimen for ending early pregnancy.)
At the clinic, Holly was prescribed an alternative or evidence-based medical abortion regimen that was not approved or evaluated by the FDA. Alternative regimens are routinely used by 99% of clinics. While there, she was given mifepristone, the first of the two-drug regimen, and instructed to self-administer misoprostol at home the next day. She was prescribed painkillers and told to return to the clinic on the seventh day to confirm termination.
Three days after her procedure, Holly called the clinic hotline to complain of severe abdominal cramping. She was told her symptoms were normal and to take the clinic prescribed painkiller. If her symptoms didn’t improve she was instructed to go to the emergency room.
On the fourth day, still experiencing severe cramping and bleeding, Holly went to the emergency room. The doctor there, whom she told about her abortion, sent her home after an injection of a narcotic pain medication.
The severity of the pain continued. Holly was weak, vomiting, and unable to walk. In the early morning hours of the seventh day, she was re-admitted to the same hospital. She died later that afternoon with her father — who had just learned of the pregnancy — at her side.
Months after her death, it was discovered by the CDC and the FDA that Holly had tested positive for Clostridium sordellii toxic shock syndrome following medical abortion. This was the first case of fatal Clostridium sordellii after medical abortion reported in the United States. Since 2001, there have been eleven FDA reported medical abortion deaths from sepsis. Nine of these were from Clostridium sordellii.
Call to Action: Ideas & Innovation:
- Additional Innate Immunity Research: Mifepristone used for medical abortion has known pharmacological properties that may alter or impair the innate immune response predisposing to serious or fatal infections.
- Reevaluating Systematic Reviews, Grades and Guidelines for Evidence-Based Medicine: Important for patient safety when levels of evidence and recommendations may be subject to bias when made by certain industry experts and insiders.
- Timely Identification of Patients at Risk: Additional support is needed to ensure appropriate therapies for sepsis are initiated in a timely manner.
- Implementing Molecular Diagnostics Applications: Institutions of any size need the ability to perform sophisticated genetic testing for organisms where accurate, rapid, and actionable test results are needed most, such as identifying and managing infectious diseases including Clostridium sordellii.
For more information, please visit the website: http://abortionpillrisks.org/
Patient Stories
Roger Jukich
As told by Roger's wife, Barbara Jukich
My husband, Roger, was admitted to a South Carolina hospital with pneumonia and an embolism. He began to improve and after a week in the hospital we were told he was ready for discharge.
Then the hospitalist shared with us that Roger had gotten too much blood thinner and said he was stopping his Lovenox shots immediately. But before he entered this important change into the medical record, a nurse came into the room with an injection. We told her the doctor had stopped injections and instead of checking with him, she proceeded to give another overdose, stating, “This will be the last one.” She was correct. It was the last one and it nearly cost my husband’s life.
Later that evening, Roger complained of side pain. The nurse did not come to the room but told her aide by phone that it was gas. When he complained later that the pain had gone to the other side, I heard her tell the aide on the phone to say the gas had moved to the other side. To make a diagnosis with second-hand information over the phone to an aide is not acceptable.
When we finally did see the nurse, we asked about pain medication. She said he could have either Tylenol or morphine. We both said out loud, “No morphine!” A few hours later she came into the room and gave him a shot. When I asked what it was she said, “Morphine,” and added, “That’s how we do things around here.” If the nurse had checked, she would have seen that Roger had severe bruising across his entire stomach and sides, a telltale sign of internal bleeding, especially with pain present. She did not check with or report his condition to the attending physician.
Roger was in a stupor for about 15 hours bleeding to death with no rescue in sight. The physical therapy team tried to get him on his feet the next afternoon and both times he collapsed backward onto the bed with eyes rolling. They also did not call the attending physician. As I watched his blood pressure plummet downward to a critically dangerous level, I finally screamed to get a doctor. The doctor came in and immediately rushed him to the critical care unit.
In critical care, they found every organ in his body had failed. The physicians were lined up outside his room with specialties in liver, kidney, heart, lung, etc. They worked extremely hard to save his life. While there he bloated up and had to have his wedding ring cut from his finger. He endured so much pain and suffering among other things with veins collapsing and had to have surgery to put an IV in his neck.
My question is: How does a patient go from pending discharge to every organ in his body shutting down? There is a clear explanation. Roger was the victim of one of the most common causes of death/near death experiences in hospitals across the nation, namely blood thinner overdose and “failure to rescue.” This could have been prevented if the people assigned to care for him had paid attention to their patient.
My husband left the hospital a broken man. He had been an active, robust man working 50-70 hours a week at a power plant and walking around the plant and staircases on a regular basis. When he entered critical care they could no longer hold his job for him. He was our breadwinner and it broke his heart and spirit that he could no longer provide for us.
Roger only lived another year. The assault on his body ultimately proved to be too much. The world has lost a fine man. We missed our 50th wedding anniversary last June and he will not be here for the birth of his grandson. Roger deserved better. He should still be with us.
Patient Stories
Jerry Carswell
As told by Jerry’s wife, Linda Carswell.
On Monday, January 19, 2004, my husband Jerry Carswell entered the emergency room and was quickly diagnosed with a kidney stone. He was given multiple injections of morphine and Dilaudid to relieve the intense pain. Later that day, he was admitted for observation and further tests. The physician began an aggressive regimen of additional narcotics and Toradol by IV to control the pain.
Jerry’s hospital stay was prolonged by an elevated creatinine level, which his physician thought was discontinued. Jerry continued to receive other pain medication. His pain was moderate and he was scheduled to go home Thursday if lab results tests showed that his creatinine levels were returning to normal. But Jerry never left the hospital.
I received a call around 6:00 Thursday morning: “Your husband had an emergency. Can you come to the hospital?” When I asked for details, the nurse simply asked how long it would take for me to get there.
When I arrived, a nurse guided me to an empty patient room. With her was a young woman I had not seen before. She looked at me and said, “Your husband is dead.” The nurse added, “He died peacefully in his sleep. You can take comfort in that.”
My shock was so complete that I could not process their words. I turned and ran to Jerry’s room – I tried to wake him – tried shaking him – and finally collapsed in screams and sobs. The nurse stood in the doorway: “Doesn’t he look like he is just sleeping? He looks so peaceful, doesn’t he?”
I got no answers to my questions. The young woman who had announced Jerry’s death was gone. I later learned that she was the new, inexperienced on-call physician for the urology group. The charge nurse would not supply any information or details. She just kept saying Jerry had died “peacefully.”
After Jerry’s funeral, I ordered his medical records and learned that he had been found lying “unresponsive” across the end of this bed by the phlebotomist who had come to draw blood at 5:15 a.m. The code team worked for 25 minutes and administered repeated doses of Narcan, a drug used to reverse drug overdose. These startling facts were in direct contrast to the “peaceful death” described to me by hospital employees.
We learned that at 3:30 a.m. Jerry had been give 75 mg of Demerol with 25 mg of Phenergan, injected intravenously all at once. No vital signs had been recorded in his chart before or after, and no one went back into his room to check his reaction after this concentrated dose of narcotics. The LVN who administered the drugs later stated she did not understand that Phenergan enhanced the effect of Demerol on the respiratory system. When she spoke with the on-call urologist at 3:30 a.m. she did not mention the pain medications Jerry already had in his system.
I asked for an autopsy by an independent pathologist or the county medical examiner. I was told that the on-call physician had requested a hospital autopsy that would be “the same” as one done by an independent pathologist. Too late I learned that, unlike a medical examiner or independent pathologist, a hospital pathologist does not investigate a possible drug overdose. The hospital pathologist did not determine a cause of death. In a sworn statement, he stated that as a hospital pathologist who had performed over 1000 autopsies, he had never done a drug panel to screen for possible medical errors. Three years later, we learned that Jerry’s heart had been retained by the hospital pathologist without my knowledge or consent. We are still attempting to gain possession so I can bury his heart and finally put my husband to rest.
Patient Stories
Mark Hoefen
Mark was 26 years old and living in Florida. He collapsed one day while out with friends and suffered a traumatic brain injury. He was taken to the hospital, where he was fully conscious until he was placed into a drug-induced coma.
On the second day in the hospital, Mark developed pneumonia, probably due to a mishap with his feeding tube. His parents were told that all was well and that it was a matter of time before he would awaken. On the fifth day, Mark’s mother was informed that he was in serious condition. The doctor questioned Mark’s parents about their son’s use of cocaine. Mark was not a cocaine user, and had not been in the past. That being established, the doctor mentioned that the culprit might be the propofol Mark had been given, and said he would recommend dialysis as a treatment for propofol poisoning. Another team of doctors came in, however, and decided Mark wasn’t ready for dialysis. This was a major error, according to later reviewers of Mark’s record. On the final day, a new doctor said he would move Mark to the cardiac unit and give him dialysis. Mark was prepared for dialysis but never received it. After this doctor left, Mark was not moved to the cardiac floor but to the basement, where he was placed in a barren room without even a char. The parents later learned from the medical records that vital medication had been considered and declined.
As Mark’s parents were visiting him in his new room, a nurse told them there was an emergency and asked them to leave the room. The next news they got was their son was dying and that treatment was futile. Mark’s parents were brought back into the room and he died in his mother’s arms.
The medical examiner ruled that Mark’s death was due to excessive bleeding caused by alcohol and drug abuse. Mark had no history of substance abuse; blood work done at the hospital had shown no drugs in his system and the equivalent of one light alcoholic drink. Later, Mark’s parents had his records reviewed by an independent physician who said that their son’s rapid decline was caused by a condition called propofol infusion syndrome. The reviewer also found many other system failures in Mark’s case. Because Florida law forbids lawsuits over the death of adult children, Mark’s parents were not able to get the answers they were seeking about his care. They wrote the hospital and received a written apology acknowledging poor communication, but the hospital refused to meet with them. They were, however, able to get a retraction of the coroner’s erroneous report that their son had died as a result of substance abuse.
Patient Stories
Josie King
As told by Josie's mother, Sorrel King
Josie King was admitted to the hospital after suffering severe burns from climbing into a hot bath. She had healed, and was set to return home two weeks later. Josie died days before she was to be released. She had an undetected central line infection and severe dehydration.
After she left the PICU, Josie’s central line was removed. Every time she saw a drink, she screamed for it. She was sucking feverishly at her washcloth. Josie’s mother asked the nurses about this and was assured it was normal, although it was not something Josie had ever done.
Sorrel King had been with her 18-month-old daughter every minute from the day she entered the hospital. The nurses assured her Josie was doing well, and suggested it was time for Mrs. King to sleep at home.
Arriving back at the hospital at 5 a.m., Josie’s mother knew something was drastically wrong. The medical team was called. They administered Narcan, and Josie’s mom asked if she could give her daughter something to drink. Josie gulped down a litter of juice. Verbal orders were given: no more narcotics. Josie began to seem a little better.
At one o’clock, the nurse entered with a syringe of methadone. Sorrel told her there was an order for no narcotics. The nurse responded that the order had been changed, and gave Josie the injection. Soon after, Josie’s heart stopped. Her mother was ushered out of the room.
The next time Sorrel saw Josie, it was back on the PICU floor. Her child was hooked up to many monitors and looked awful. Eighteen-month-old Josie King died in her mother’s arms two days later. She had a hospital-acquired infection, was severely dehydrated, and had been given inappropriate narcotics.
Patient Stories
Emily Jerry
As told by Christopher S. Jerry
Emily Jerry was diagnosed with a yolk sac tumor about the size of a grapefruit when she was about 18 months old. Her doctors and nurses assured me that Emily’s cancer was not only treatable, but curable.
Emily endured months of surgeries, grueling testing, and rigorous chemotherapy sessions. Emily’s treatment had been so successful that her last MRI showed there wasn’t even any residual scar tissue. Emily’s doctors said it was as if she never had cancer.
Regardless, she was scheduled to begin her last chemotherapy session on her second birthday, Feb. 24, 2006. This was just to be sure that there were no traces of cancer left.
Sunday, Feb. 26, after the third day of her last chemotherapy treatment, Emily awoke from her nap groggy. She kept trying to sit up and asked her mom to hold her in her lap. She kept grabbing her head and moaning that it hurt. Emily spotted her mother’s can of Coke that she had on the tray and begged to have a sip. She sipped the rest of the can through the straw in a matter of seconds. She cried some more before she started screaming, “Mommy, my head, my head hurts! MY HEAD HURTS!”
I was just walking in as nurses were grabbing her from her mom’s arms. Emily went completely limp and the nurses began to resuscitate her. Within the hour, my precious daughter was on life support.
Emily wound up brain dead and on life support – essentially dead due to the massive brain damage she had incurred. Our Emily was killed by an overdose of sodium chloride in her chemotherapy IV bag.
We had planned a belated birthday and a cancer-free party for her. Instead, Emily was delivered to the Cuyahoga County Morgue.
My family has been completely destroyed by the preventable and tragic death.
A pharmacy technician who had been working for the hospital for a number of years decided not to use a standard prepared bag of sodium chloride solution (with less than 1% of sodium chloride solution).
Instead, the pharmacy technician filled a plastic bag with a concentrated sodium chloride solution of 23.4%, which she had compounded herself.
When the pharmacy board investigators and others investigating Emily’s death asked the technician why she had made this outrageous error, she replied that she did not know. The pharmacy technician was asked if she knew that an overdose of sodium chloride could result in death. She claimed that she was not aware of that fact. How can a person who works in a pharmacy and compounds medications daily not know that?
At the time of Emily’s death, Ohio didn’t even register pharmacy technicians. In fact, there weren’t even any training or licensing requirements.
