“Oops” Not Welcome Here (your Hospital…your Drug Store…)

November 20th, 2009. By Hunter West

There are some jobs that should be held to a higher standard. Like holding public office, or serving as a priest, or acting as someone’s surgeon. Maybe you’re about to amputate a limb…and the patient assumes you know the correct one to remove. 

Well, as experience has taught us—not always. 

Here’s a couple of examples of ‘oopsies’ that are unforgivable. Imagine if this happened to you… 

Oops #1: Wrong Kerry, Wrong Test

Kerry Higuera was three months into her pregnancy when she started to bleed. Fearing a miscarriage, she headed to her local emergency room. It seemed the prudent thing to do. 

According to CNN she was put in a room that February morning last year in Arizona and was told to wait until a nurse came by to get her. 

Soon enough a nurse poked her head in and said, “Kerry?” Kerry said yes, she was Kerry. Well, off they go to the CT scan room. “Is this really what I need to have done,” asks a reluctant Kerry, assuming that radiating her abdomen containing a three-month-old fetus can’t be healthy. The answer was yes. “This is what the doctor wants…” 

You can imagine Kerry’s panic when, soon after having the CT scan on her abdomen Higuera was visited by the emergency room physician, two radiologists and someone representing the human resources department of Banner Thunderbird Medical Center in Glendale. 

“We made a mistake,” Higuera recalls them saying to her. “We did something we shouldn’t have done. There’s another patient here named Kerry, and you two are the same age. We mixed you up. She was supposed to have the CT scan, not you.” 

Oops #2: Right Girl, Wrong Medicine

Now, consider the story of Wilma O’Neill. When she went to her local Walgreens drugstore in Modesto last week, she assumed she had been given an antiviral drug to treat her daughter’s bout with H1N1 flu. She gave 5-year-old Ellen two doses, according to the instructions. 

Then she got the call from the pharmacy. Someone had gotten the wrong medication and they were trying to straighten things out. Upon taking what she believed to be an anti-viral medication back to the store, it was only then that Wilma realized the true gravity of the situation: she had given her young daughter a powerful heart medication by mistake. 

Although Ellen seemed fine, the pharmacy advised Wilma to get her daughter to emergency right way. An initial electrocardiogram appeared to show all was well, but a follow-up EKG showed an irregular heartbeat the next day. 

It turns out what the pharmacy dispensed to Wilma was not an antiviral at all, but a pediatric form of amiodarone, a drug used to treat irregular rapid heartbeat when all other meds fail. In following the dosing instructions for an antiviral, Wilma inadvertently gave her daughter twice the normal dose of amiodarone. 

Oops Aftermath: Awaiting the Fallout

The Modesto Bee reported November 10th that O’Neill would not know for sure if her daughter Ellen would be okay until an examination by a pediatric cardiologist. But it could have been worse. What if the pharmacy hadn’t called? What if the error had gone completely undetected? 

In the case of Kerry Higuera, it was too late. Her baby had already been irradiated before the error was discovered. While no large studies have been done on the effects of performing a CT scan on a pregnant woman’s abdomen and the impact on the fetus, experts say a fetus exposed to radiation can, in some cases develop physical and mental growth problems. So Kerry doesn’t know if her baby is going to be okay, or not. She has since given birth. Doctors are watching her son’s development carefully. 

Higuera is also represented by legal counsel. 

Oops…More Common Than You’d Think

The Joint Commission, which accredits hospitals, reports that wrong-site, wrong-side and wrong-patient procedures occur more than 40 times each week in the US.

Meanwhile a 2003 Auburn University study on pharmacy errors estimated they would occur four times a day at pharmacies filling more than 250 prescriptions daily. One in 1,000 of those errors will constitute a threat to patients’ health, the study said. 

Mistakes will happen. That’s human nature. But in the area of medicine, with such a fundamental impact on human health, where is the oversight to ensure mistakes don’t happen? Walgreens did not indicate how the O’Neill gaffe was discovered, but said the chain employs a number of safety checks to reduce the possibility of human error. 

Why stop at reduction? We should be talking elimination. Find a way of constructing oversight and a series of checks and balances so that never again will a five-year-old child be given a heart drug instead of something to fight her flu. Never again should a young mother with a precious fetus in her womb be mistaken for someone else (note to hospital: people have last names for a reason) and have her developing child bathed in radiation. 

Earlier this month in Rhode Island, state regulators took the unusual step of requiring video cameras in all operating rooms at Rhode Island Hospital after a spate of errors.

At least six surgical errors have occurred at Rhode Island Hospital since 2001, including one where a child went in for eye surgery and the surgeons, confusing this child with another patient, took out the tonsils instead. 

Another child had cleft palate surgery on the wrong side of the mouth. Another patient went in for neurosurgery and doctors drilled holes on the wrong side of the head. 

How does this happen?

Back in Arizona Higuera says the doctors were “very nice,” and “said they were sorry over and over again.” 

She says the emergency room doctor, who was also pregnant, cried as she apologized to her and her husband. They offered free coupons to the hospital cafeteria. They asked what kind of flowers she liked, that she would have flowers waiting for her when she arrived home. 

Can you believe it? 

Higuera says the doctors explained to the couple that their baby could have mental retardation, a low IQ or growth problems because of the radiation exposure. 

Nathan Higuera is now 15 months old. His pediatrician is aware of Nathan’s situation, according to Nathan’s medical records, provided to CNN by Higuera’s lawyer. 

“MOM EXPOSED TO RADIATION DURING FIRST TRIMESTER,” reads one comment in the pediatrician’s notes. “CHECK DEVELOPMENT!!!” 

In the pediatrician’s records, it’s noted that at 3 months of age, Nathan’s head circumference had been in the 73rd percentile, but that at his 1-year checkup it was in the fifth percentile. Pediatricians often consider it a red flag if a child’s growth does not stay in the same percentile range. 

The records also note that Nathan would be referred to a specialist soon if his growth and development “is not that great.” 

No wonder litigation lawyers are busy. Someone, somewhere—give your heads a collective shake and get with the program. 

Cafeteria coupons and flowers just don’t cut it.

Tags: hospital errors, medical errors, medical malpractice, pharmacy errors

This was posted on Friday, November 20th, 2009 at 11:12 am and is filed under Drugs/Medical . Feel free to respond, or trackback. Read our comments policy.