Learning From The Mistakes Of Others

The California Department of Public Health routinely publishes a list of fines to hospitals which have made egregious errors that caused the death or permanent injuries to patients when the proper safety protocols are not followed. The fines can range up to hundreds of thousands of dollars for facilities with multiple recurring mistakes. The state conveniently publishes the results of their findings so that others might learn from the mistakes of others. This month the list includes twelve hospitals. Many are the "routine" so called never errors like leaving a lap sponge inside a patient during surgery. However I'd like to highlight one particular case that I thought was very instructive. The case involves one of our local SoCal hospitals: Kaiser Foundation Hospital of Harbor City.

According to the report, the patient was admitted to the hospital in 2010 for hematemesis. A nurse reported the patient vomited bright red clots of blood. After the patient was intubated in the ICU, she was taken emergently to the operating room. During the procedure the surgeon noted that the patient was coagulopathic. He requested Factor VII be given to help clotting. The CRNA in the case told the state investigator that he gave a drug that was given to him by the supervising anesthesiologist without ever confirming its contents because he "put his trust in [my] supervisor and took the bottle of medication" and pushed it into the patient. The patient made it out of the OR but continued to bleed profusely. When the surgeon asked for more Factor VII to be given in the ICU, the pharmacist said he had not sent any to the patient. He had sent Activase instead. Activase actually prevents blood from clotting and is used to treat patients with blood clots causing an ischemic stroke or heart attack.

When interviewed by the investigators, the circulating nurse in the OR said he had written down Activase on a piece of paper when the surgeon made the Factor VII request. When the drug arrived to the OR, he repeated "Activase" three times to the surgeon. The anesthesiologist in the room said he heard the surgeon call out for Factor VII but admitted that he never looked at the medication he was given by the nurse before giving it to the CRNA. He concedes that the protocol is to confirm the identity of every drug by reading its label before administering it to the patient.

The patient eventually died later that day. The cause of death was listed as "periprocedural administration of alteplase". (the generic name for Activase) As usual, when a catastrophic error occurs, it is not a single mistake that happens but a series of chain reactions. The surgeon said he asked for Factor VII, which was confirmed by the anesthesiologist. The nurse said he heard Activase and confirmed three times with the surgeon. The nurse gave the drug to the anesthesiologist who did not read the label because he either put his complete faith in the circulating nurse and pharmacy or he was too busy with a critically ill patient. He drew up the drug and gave it to the CRNA who did not look at the drug label either because he he never questions his supervising anesthesiologist. And the patient died as a result of all the mistakes committed by several different people.

Though it's tough to air your dirty laundry in public, this is how medicine polices itself. Though Kaiser was fined by the state for $50,000, hopefully this will be a small price to pay to ensure that other hospitals won't make the same missteps and tragic outcomes.