A Hospital Death in Florida


    Kevin, M.D. – Medical Weblog: A woman dies after receiving 8 grams of Dilantin

    I read about this on the blog linked above and the source article is here.

    A nurse administered an incorrect dose to a patient, TEN TIMES the normal dose and well above an amount that would have been fatal, so of course it was a fatal incident (or “sentinal event”) as hospitals would call it.

    Rohart, an ER specialist for eight years and a doctor since 1989, said he ran tests and prescribed 800 milligrams of the anti-seizure drug Dilantin.

    But Cooper [the RN] instead administered 8000 mg (eight grams), quickly stopping Plass' heart, hospital officials said. The fatal dosage is two to five grams.

    The article doesn't say what the error was that led to 800 becoming 8000. I can't imagine it was a decimal place error. How could this have happened?

    I'm normally quick to place blame on the system, but this one comes close to really seeming like the mistake of an individual:

    The correct dose required 3.2 vials of the drug. Cooper gave Plass 32 vials, hospital administrator Joe Scott said. To get that many, she had to search the halls and take every vial from three computerized drug-dispensing machines, he said. “That would be a big red flag,” Scott said.

    All the Dilantin didn't fit in one intravenous bag, so Cooper hooked up two, one in each arm, Scott said. “That would be another big red flag,” he said.

    Cooper never double-checked or questioned the amount, Scott said. Nor did she explain her error to hospital officials, he said.

    It would be a big red flag, I guess, but nurses are often scrounging for drugs in the hospital due to stock shortages and poor replenishment processes. But still…. yeah, it seems like she should have at least asked somebody. That's part of the problem with hospitals — the culture of workarounds and “just getting the job done” instead of stopping to proactively fix problems. In a better hospital culture, the RN would have had someone to ask or at least make the suggestion, “We should stock more of this drug, I've had to look all over.” A supervisor could have or should have caught it or questioned the action. The culture of workarounds and heroic measures means that, even in less fatal situations, that RN's are constantly fighting the same fires and battles every day, without root cause problem solving.

    After the tragic death, the hospital took some systemic steps beyond firing the RN:

    The death exposed gaps in safety procedures, Scott said, mainly that the drug-dispensing system did not detect such a huge dosage being prepared for one patient.

    The machines have been reset to flag large withdrawals and to stock only small amounts of Dilantin and other high-risk drugs, forcing nurses to go to the hospital pharmacy in person, he said. After the death, the hospital retrained nurses and tested them on calculating dosages.

    “I have a sense of comfort that they have taken all the steps necessary,” Levine said.

    OK, why wasn't that systemic fix put in place BEFORE? Will OTHER hospitals learn from this error and make sure similar protections are in place?

    Also, RN's already struggle through enough systemic waste and non-value-added activity each day without forcing them to take a long trip to the pharmacy, taking them away from their patients.

    There's a whole other subplot in the story about how the hospital warned the doctor to not ask questions about the death, which smells like a cover up attempt… that's a post for a different blog.

    A call to all hospitals: Be proactive about preventing mistakes, don't wait for a death to respond. Learn from the mistakes of others so you can prevent this particular type of error from happening ever again, anywhere. Establish a culture where people don't have to be heroes, where they can ask questions and question things or ask for help without being viewed as lame or weak or incapable.

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    Mark Graban
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


    1. Some time ago, I read about a study where a pharmacist accompanied a doctor on rounds. Doctors don’t always know all the alternatives to drugs they are used to prescribing, and may not be as sensitized to interactions. In the study, errors fell and outcomes were better. Seems like more pharmacists at the gemba could prevent a lot of trouble. And could save the nurses a lot of running around if they had the responsibility for restocking and locating. That might save enough to pay for additional pharmacists.

    2. Some hospitals DO staff pharmacists out in the units. I’ve even heard of some that are doing away with the giant centralized pharmacy and going to multiple satellite “point of use” pharmacies throughout the hospital.

      I’m sure there are tradeoffs, but it’s an interesting concept.

    3. The article made one comment that caught my attention:

      After the death, the hospital retrained nurses and tested them on calculating dosages.

      When I consulted at a nuclear facility a few years ago there was a similiar solution to a problem on lock out tag out of a radioactive area.

      A poka yoke solution could have easily solved the problem but they still insisted on training everyone.

      I wonder what the impact on a production line would be if every time there was a mistake there was a training session for all employees from all areas on the production line when 5 Why’s and poka yoke could solve the problem?

    4. Whenever I see medical records, handwritten by the doctor, I always note that they are almost un-decipherable, and that it’s really amazing that the rate of errors made by whoever is reading them – pharmacies, nurses, etc. – is not somewhere at 50% at least. It’s really amazing that with all computer technology out there, the doctor is handwriting important information where, indeed, misplaced period can take someone’s life.

    5. “To get that many, she had to search the halls and take every vial from three computerized drug-dispensing machines, he said. “

      It looks like the pharmacy isn’t up to date, otherwise, the the computerized drug-dispensing machines should have kicked in and sent up the red flag, PDQ.


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