Sharing Their Story to Prevent Fatal Medical Errors A few weeks after beginning treatment for non-Hodgkin lymphoma in 2005, 21-year-old Christopher Robin Wibeto told his mother Debra that he wasn’t afraid to die. As most mothers would do, Debra said she wished she could take her son’s place. 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. Debra remembers the graceful and delicate way in which the doctor broke the news, and the equally graceful way that her son received it. The result—Liberace’s face was so tight that he couldn’t fully shut his eyelids, even when he was sleeping. I am fortunate to know most of what happened to Gabriel. . He left one patient in the operating room so he could go to Las Vegas. It’s fairly easy to determine how much of the drug to give to someone. Her home medication list had stated “0.0625” for the Digoxin, but did not include the unit, and was not checked during medication reconciliation. He died a long time ago – it happened in the same days Hurricane Katrina slammed into the Gulf. A mother-of-four died after a nurse at a trouble-hit hospital trust gave her ten times the amount of drugs she was supposed to receive. . ] It was like a bad dream that you can’t wake up from.”. “We hope that this story will help in some ways to prevent another family from suffering this horrible loss.”. At first, the results seemed to defy reality, so much so that Young recommended Dr. Startz to all her friends and clients. Even though our Emily was diagnosed with this frightening form of cancer, her team of doctors and nurses assured me that Emily’s cancer was not only treatable but highly curable! "Common practice had become - incorrectly - not to label syringes when only one medication is used," says Haas. MIMS lists some of these near-fatal and fatal cases that were committed by nursing health professionals. The transfer medication list included “Digoxin 0.625 mg daily.” However, she was actually taking 0.0625mg. She takes solace in the conversation she had with Chris in the weeks earlier, knowing he wasn’t afraid to die. “I can’t imagine what Chris was thinking in that moment,” she said. About prescriptions, she said: “Make sure you really read your prescriptions, and make sure it’s the right thing.”. Vecuronium injected instead of Versed. A Trail of Medical Errors Ends in Grief, But No Answers. was wrong." Vanderbilt’s Role In The Death Of A Patient. Startz agreed to do this, too. Because he was so susceptible to infection, Garcia required frequent antibiotic treatments. However, despite these protocols, they failed to catch the fact that English was receiving the wrong blood type. As usual for someone in a hospital, Warhol received fluids to remain hydrated. Luckily, he managed to survive. He couldn’t stay awake, and one day, he fell asleep and never woke up. Coleen called the pharmacy and described the pills to the pharmacist along with their effects. When you’re on the operating room table, your life is quite literally in the surgeon’s hands. . The errors range from medication overdoses to surgeries performed on the wrong body part to X-rays read backward. Instead of learning how to assess and respond to errors we are taught to suppress and ignore, as happened in my situation. He was then referred to Dr. Christopher Duntsch for spinal fusion, a delicate surgery that worked directly with the nerves in the spinal cord. Donald Church, 49, had a tumor in his abdomen when he arrived at the University … Other patients of Duntsch also complained that they only grew worse after seeing him. There are multiple layers of safety checks from the moment the blood leaves the blood bank to when it’s finally given to the patient. Rhode Island Hospital – Brain Surgery Disaster. Alyssa was admitted to a Denver hospital, where she was diagnosed with leukemia. Using the Wrong Administration Route. An inquiry found that at the time of his death, Warhol was anemic. The next day, he complained of a stomachache. Dr. Randall Kirby, a surgeon who assisted Duntsch, claimed that he had a surgical technique like a first-year medical student and had little to no knowledge of the spinal system. Our laws perpetuate this process by treating malpractice cases as the fault of single individuals instead of systemic failures.There is no safe space for medical professionals to openly discuss errors without fear of repercussions. Why had Warhol died after a routine procedure? To alleviate the symptoms of a patient’s allergic reaction, a … This is not a common phenomenon in any way. In 1979, Liberace, the world-renowned showman, watched himself on The Tonight Show and was horrified by what he saw. Two years ago, an investigation looked at 45 fatal errors with medicines that were taken by people in their home.4 The medicines most frequently involved in the fatal errors at home included: To improve medication safety in the home, follow these recommend ations: The majority of deaths in the analgesics group were associated with opioids. The Nashville District Attorney has assigned full blame to her for the death of Charlene … Joyce Karney writes poetically about the pain of losing her soul mate Glenn, and the struggle of adapting to a new life without him. At the time, there was no test that could determine whether or not the kidneys were infected with the parasite. When the cardiologist rounded early that morning, he wrote an order that the Pronestyl drip be discontinued. According to the Food and Drug Administration, medication errors jumped from 16,689 in 2010 to more than 93,930 in 2016. You can write him at [email protected]. She tried to contact Dr. Startz, but he didn’t return her calls. He was admitted to the ICU. He just took in this terrible news and went on. Barry Morguloff’s surgeon, on the other hand, was a man who committed numerous violations and should have never been allowed to practice medicine. Even before they knew what had in fact occurred, the nurse administrator activated a task force in the operating room to look at the process. The silicone in her face began to shift and move, severely deforming it. While it would be convenient to say that a careless nurse caused my suffering, I know there is more to the story. He skipped five drug tests during his time at the hospital. Jessica was having a typically busy day on Tele. He was given steroid injections, but they didn’t help. She claimed that she was not aware of that fact. Regina Turner endured many people’s worst nightmare concerning surgery—receiving the wrong operation. . He had been unattended, and internal pressure built up, causing heart failure. When asked why Piedmont Hospital did not tell the family the true cause of death, they responded by saying that they never revealed anything about a patient’s death until there was “full information to share.”. He was given painkillers, but after six months, he was still in pain. He soon found a gold mine in silicone injections. He died at a hospital that had people brave enough to face me, bold enough to take responsibility, compassionate enough to explain. Gordon Gora is a struggling author who is desperately trying to make it. Rather than a left-side bypass, she had been given a right-side bypass, which caused considerable damage to her nervous system. It became clear that the kidneys were infected with a rare parasitic worm called Halicephalobus gingivalis, which is primarily found in horses. The condition that Warhol died from could have been easily treated if someone on the staff would have simply paid attention. He was prescribed an antacid, which he received from his nurse afterward. Despite their best efforts, doctors couldn’t help Alyssa, and she soon died. While they should have been destroyed, they were instead given to two unfortunate patients. While in the hospital, Garcia had been prescribed the drug Septra for his infections. The tumor was the size of a grapefruit inside her tiny little abdomen. After becoming CEO of NCCN in 2013, he worked closely with that national cancer organization to help prevent medical errors with vincristine. Premature twins born at the scandal-hit Stafford Hospital died after receiving an overdose of morphine administered in error, a Nursing and Midwifery Council hearing has been told. How could such glaring mistakes have been committed by a supposedly accredited surgeon? Rather than question the machine, the nurse doled out the pills. The drug had put him into respiratory arrest. The study found that fatal medication errors spiked by 10 percent in July in counties with a high number of teaching hospitals, but stayed the same in areas without teaching hospitals. We can generally agree that technology has vastly improved our lives, but it can still make mistakes, as can the people using it. And she said nurses don’t take the errors lightly. The Nashville District Attorney has assigned full blame to her for the death of Charlene … The program had been set to “milligrams,” which means that it would calculate how many milligrams of a drug should be given based on how many kilograms the patient weighed. Tragic and preventable errors dot the recent history of medicine; some were so glaring that they led to important changes in patient care. It turned out that a doctor had noted Alyssa as “anxious,” so she was given Ativan, which could have covered up her symptoms. Now imagine how bad it was when a 12-year-old girl was given the drug by accident. “RaDonda has to wake up … After his death, his organs were rightfully rejected for donation because of their poor functioning, and the cause of death could have caused complications for any recipients. In the case of Beverly Hills surgeon Jack Startz, celebrity plastic surgery took a dark turn. *The name, photograph and contents of this story are … "RaDonda has … After that, her family couldn't get accountability. He performed them constantly without any regard for his patients because he needed the money. it wasn’t an antacid. Recently, his horrifying practice has come back to light due to the HBO film Behind the Candelabra, where he is portrayed as an eccentric surgeon who will do anything for his client, Liberace. The pharmacy technician was asked if she knew that an overdose of sodium chloride could result in death. Her home medication list had stated “0.0625” for the Digoxin, but did not include the unit, and was not checked during medication reconciliation. She tried to remove stair railings, thinking they were curtains, and saw other frightening manifestations. Alyssa did not die in vain, though. The "second victim" crisis. Alyssa wasn’t killed by leukemia. 44 units of Lantus was ordered for bedtime, but there was also an order for 44 units of regular insulin. “In one instance everything changed. Not only was Duntsch completely incompetent, but it also became clear that he was using drugs while working. Despite this, Liberace wanted his partner, Scott Thorson, to receive plastic surgery to resemble a younger version of himself. The surgeon also has to mark exactly where the surgery is to be performed. This was the case when a 16-year-old boy named Pablo Garcia was admitted to the hospital for a colonoscopy to examine intestinal polyps. In 2010, Smith was undergoing dialysis when he started to experience shortness of breath. *The name, photograph and contents of this story are … These three medication groups were associated with 40% of all reported errors, 50% of severe harm errors and 60% of fatal errors, somewhat similar to other studies.3 5 15 22 Most fatal errors were associated with analgesics and antithrombotic agents. When we go to doctors, we usually trust them to do their best to try to help us. In his deposition, Bazemore said he could not link the overdoses of Dilaudid to Powell's death because of the time that elapsed between the second 4 mg dose of Dilaudid and Powell's time of death. [ . A Doctor Confronts Medical Errors — And Systemic Flaws That Create Mistakes : Shots - Health News Dr. Danielle Ofri says medical errors are more common than most people realize: "If … However, his girlfriend quickly noticed that something was wrong. Despite having a phobia of hospitals and doctors in general, he agreed to the surgery, which seemed to be successful. One of her patients, a middle-aged male in Room 4152, was on a Pronestyl drip for arrhythmias. In 2007, nine-year-old Alyssa Hemmelgarn became sick and didn’t seem to be getting any better. It wasn’t his condition or the procedure that killed him but rather a mislabeled blood transfusion. The results were scary: Elaine Young, a celebrity realtor, was a high-profile victim of his practice. Glyn was autistic and died following a fatal delay in diagnosis Errors in prescribing led to George’s death after he suffered head injuries following a fall Heather suffered permanent damage as a result of negligent treatment in hospital Lyndsey died following medication errors and a … was wrong." At a press conference in 2016 announcing the launch of the program, Debra and Robin remembered their son, and explained what they hoped to achieve by sharing his story. He went to ear, nose, and throat specialist Jack Startz, who agreed to perform the procedure. Giving the wrong drug and using the wrong route of administration each accounted for 16% of the errors. After a week of treatment, Alyssa seemed to be doing better. The reason Startz agreed to do these questionable procedures was the fact that he was experiencing financial problems related to his own alcoholism and drug use. Unfortunately, he slipped into a coma and soon died. Garner said medication errors happen all the time but usually the public is unaware of them. Pronestyl is an antiarrhythmic drug that has pro-arrhythmic properties and a therapeutic range must be maintained. Emily endured months of surgeries, grueling testing … 6 Medication Error Stories That Made Headlines 1. The transfer medication list included “Digoxin 0.625 mg daily.” However, she was actually taking 0.0625mg. I know because I was told. Both patients accepted them and died from meningitis soon after. Being involved in direct patient care, nurses run the risk of committing medication errors. In adults, Ambien can ease insomnia; in a child, it can have terrifying mental effects. A few weeks after beginning treatment for non-Hodgkin lymphoma in 2005, 21-year-old Christopher Robin Wibeto told his mother Debra that he wasn’t afraid to die. “Chris, upon hearing that his life would almost certainly end, just took a deep breath and said he understood. No one managed to find the infection before Alyssa died. Douglas Herman describes the touching moments at his mom’s bedside before she succumbed to bone cancer, and his subsequent journey from distressing thoughts to 40 years of endurance before he received a diagnosis of stage IV prostate cancer. . ] He had been before he was admitted, but doctors said he was in good enough condition for surgery. According to Warhol’s private physician, Dr. Denton S. Cox, the 58-year-old artist hadn’t been looked over by any physicians, and the nurses rarely, if ever, checked up on him. Since then, even if only one medication is in use, every syringe is labeled. Robin believes that if the guidelines for bagging vincristine had been in place when Chris was receiving the chemotherapy, the mistake would not have happened. Other children on the same drug have been adversely affected by … Purportedly, a technician typed the dosage into the computer system incorrectly, and the pharmacist failed to note the discrepancy when he filled it. Antibiotics pumped directly into a large vein via IV costs $50,000, which makes many doctors leery to use it unless it’s absolutely necessary. However, the nurse treating Garcia reset the program and didn’t catch that it had now been set to “milligrams per kilogram.” When she typed in his dose, 160 milligrams of Septra, it multiplied it by Garcia’s weight. Riley was taken to the emergency room, where she was told that she’d had a bad reaction to Sudafed, which she was taking for a cold. Apparently, this wasn’t enough to keep them from operating on the wrong side. However, doctors are humans, too, and that means they make mistakes. After having the wrong surgery, her health deteriorated. The conversation stuck with her, because “at the time, dying wasn’t even a thought,” Debra said at a recent press conference organized by the National Comprehensive Cancer Network (NCCN). Patients should be informed of all potential complications before starting drug therapy. That alone was tragic enough, but it wasn’t the end for Carole or Alyssa. Within three years, though, something started to go wrong. It wasn’t until a CBS investigation that English’s family learned the truth. I have had time to heal. Since her death, there have been numerous reforms in treatment throughout hospitals in Colorado. Poor communication among doctors and between doctors and patients is a common cause of medication errors. Being involved in direct patient care, nurses run the risk of committing medication errors. In one instance any chance we had been dreaming and hoping for had been squashed by a seemingly careless and avoidable mistake,” Debra said. When he was in the hospital receiving an operation for an infection, it wasn’t surprising that he needed a blood transfusion. He is working on several projects, but until he finishes one, he will write for Listverse for his bread and butter. Poor communication among doctors and between doctors and patients is a common cause of medication errors. Garner said medication errors happen all the time but usually the public is unaware of them. It took another surgery to fix it. It tore our hearts up,” Robin said. She was released and went back home. The nurse that was caring for Tyler the night of October 26 and into the morning of October 27 was not adequately trained to care for a … The actual cause was Clostridium difficile, a hospital-acquired infection that had grown more severe with each day. When Morguloff emerged from surgery, the pain was still there; in fact, it had grown worse. From 1965 to 1979, Startz had injected 2,000 people with silicone, many of whom were experiencing the same effects as Young. In a study by the FDA that evaluated reports of fatal medication errors from 1993 to 1998, the most common error involving medications was related to administration of an improper dose of medicine, accounting for 41% of fatal medication errors. “The medication error caused Mr. Keogh to develop pulmonary toxicity, which led to acute respiratory distress syndrome or severe acute lung injury,” … The med error started with an accidental duplication of an insulin order. [She] will also continue to suffer from emotional distress, anxiety, disfigurement and depression.”. Robert Stuart and Darren Hughes both needed kidney transplants, so when two arrived, it must have seemed like a godsend. Morguloff first went to the hospital complaining of back pain. 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