(Oakland, CA) Nurse in fatal error put supplement in wrong tube

[alp227]

Source: San Francisco Chronicle

(09-26) 17:38 PDT OAKLAND -- The cancer patient who died because of a medical error at Oakland's Alta Bates Summit Medical Center was killed by a nutritional supplement that a replacement nurse mistakenly put into a catheter meant for delivering medicine to her bloodstream, The Chronicle has learned.

The supplement was supposed to be put into a tube that ran into 66-year-old Judith Ming's stomach, said one source close to the investigation. Ming, who suffered from ovarian cancer and had been hospitalized since early July, died early Saturday, soon after the replacement nurse made the mistake.

The nurse, a 23-year-old woman from New Orleans, was in a state of shock after realizing what had happened, said a source who spoke on condition of anonymity because patient privacy laws prevent public discussion of many of the case's details.

The woman was one of about 500 replacement nurses brought in by Sutter Health to staff its Oakland hospital and two Berkeley campuses when the California Nurses Association called a one-day strike for Thursday. Sutter kept its replacements for five days, locking out its regular nurses until Tuesday.

Read more: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/09/26/MN4C1L9Q2L.DTL

[nadinbrzezinski]

1. I am almost betting I know what happened

exactly what happened... and it ain't pretty...

RIP to the patient and the young nurse... since I suspect what happened, I have my doubts it was fully and truly and completely her fault... but there is something to say about the system and why the California Nurses are calling for these actions. Yes, it is related.

[housewolf]

2. What a tragic story

So sad for all

[Name removed]

3. Deleted message

Message removed by moderator. Click here to review the message board rules.

[Dreamer Tatum]

5. You read it here first, folks: not union? Then you should be KILLED.

I'll repeat Rochester's opinion again: if you do not belong to a union, and you dare work at a job, you SHOULD BE PUT TO DEATH.

[CaliforniaPeggy]

4. So, the nurse mixed up the intravenous tube with a gastric tube?

There is NO excuse for this.

None.

The tubes in question look and function entirely differently. They go into different parts of the body.

This is horrible.

She might very well face disciplinary action over this.

[newfie11]

8. She needs to lose her license

This is total incompetence.

[AnneD]

9. I have mixed feelings on this one.....

If they are working as short handed as they are want to do and too carry a heavy patient load, and she could be in an unfamiliar area with unfamiliar devices, I could understand.

No one goes into medicine to harm someone and I feel sorry for all parties involved, except the hospital. Too often it is easy to just blame it on the (bad) Nurse instead of studying why these human errors take place and how we can best prevent them.

I know myself and know I cannot work more than 10 hours as my concentration wanes and my energy ebbs, and yet all that is offered in hospitals are 12 hour shifts. So rather than lower my standards for safety, I do not work in hospitals.

Also, I refuse to cross picket lines because it take a lot for Nurses to strike. I get fliers all the time and the money can be tempting. I am not surprised by a one day strike nor am I surprised by the hospitals reaction. They advertise a strike long before it happens so there is no reason for this other than the hospitals administrators being pig headed and wanting to union bust.

[Gormy Cuss]

10. Unless it's changed recently,regular Alta Bates nurses don't work twelves.

That of course doesn't mean that the replacements weren't working twelves. Also I've yet to see Sutter declare that the replacement nurses brought in for this were aligned to units where they had comparable, recent experience, although the unnamed source in Matier & Ross's column claims that they were.

Here's a clear sign that she was over her head:

The nutritional supplement, which Ming was receiving to boost her calorie intake, has a warning on the container lid explaining how it is supposed to be given to a patient. Adding to the mystery is that the attachment from the supplement's container doesn't fit the catheter that was inserted in Ming to deliver medicine, one source said.

"So she had to jury-rig it," the source said of the replacement nurse, whose name has not been released. "It was a horrendous mistake, and nobody can figure out how it happened."

Had there been even one staff nurse on the unit this may not have happened.

[AnneD]

12. Things are a bit different in California...

since the staffing ratios were passed....but here in Texas and most everywhere else it is 12 hr shifts and too heavy a pt load.

But there is a first clue...the catheter from the supplement's container did not fit the catheter in Ming's delivery device.

Pharm and med supplies are notorious for vertical integration on their devices and supplies. For example, why aren't testing strip for glucometers the same or interchangeable. The companies will give you the glucometer for free but make their profit selling you the supplies that are exclusive to their meter.

Maybe the patient had the wrong catheter installed in the first place, who knows. There are too many questions here to automatically blame the Nurse. Again, we need to step away from the blame some one for the mistakes and fire them to figuring out how and why this mistake happened in the first place. Medicine is an art that takes practice. If you want exact result, stick with accounting. In medicine there are no guarantees, only best practices.

[Gormy Cuss]

13. There are other hospitals on twelves, like UCSF, but many in the SF Bay area aren't.

I agree --I would say that blaming the nurse without looking at the full context -- that it occurred in a specialized unit when there were NO experienced-in-that-hospital's-unit nurses on board -- is foolhardy. A 23 year old nurse can't have had more than two years experience in toto, and it's doubtful that all of that was in oncology. I would imagine that was a factor as well.

The hospital administration made the decision to staff for five days with an entirely new set of RNs, but too much of the press coverage (outside of SF) frames the mistake in terms of the union's decision to go out on a one day strike. That's also looking in the wrong place for the explanation IMHO. It wasn't a wild cat strike after all.

[AnneD]

14. I guess it is the old....

there but by the Grace of God go I school of thought.

I had long talks with nurses that were trapped in the hospitals after Katrina. I will never forget the shell shocked look on their faces and their flat affect. I just can't find it in my heart to judge any Nurse.

The profit based hospitals just chew you up and spit you out. No one goes into Nursing to harm some one, but all it takes is a DA running for re-election and a Nurse makes an easy head line grabbing target. I have been a Nurse long enough to have seen that scenario played over too many times.

[nadinbrzezinski]

11. And usually you got a second pair of eyes

[abrupt]

6. does not surprise me a bit

We use to have a great hospital till Sutter took over. They only care about profits.
Took my husband to the hospital with traumatic brain injury. On three separate occasions, do to error he almost died.and when they screw up they lie, falsified records and there is no accountability

[cutlassmama]

7. same thing happened to me, but not a Sutter hospital. Still they screwed

up and falsified records. good thing an ambulance took me to a trauma center that literally brought me back to life. The nurse that was supposed to be monitoring me after surgery decided to go take a nap while I bled out 9 units of blood. It wasn't until her replacement came in that she noticed I wasn't breathing.

Yeah, it's pretty damn important to have competent staff. Peoples lives hang in the balance.

[AnneD]

15. This is what I am getting at....

when we have a culture of blame, people cover up instead of learning from our mistakes and preventing the next one....and there will most certainly be another one.

[KamaAina]

16. Um, New Orleans is exporting nurses?

The health care system down there has never returned to its pre-Katrina state. Yet there are apparently nurses there available to work as scabs out here. :wtf:

edit: Then again, who wants that one? :dunce: