Patient Safety

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Option 1: Patient Safety – Case Study

Review the case study in Chapter 6 regarding titled A Tragic Mistake(FOUND BELOW).
Review the additional information provided at the end of the case and
provide your thoughts on the following questions:

  • Should any of the individuals in the OR have been charged with a
    crime, such as negligence or involuntary manslaughter? If so, which
    individuals and why?
  • What, if any, disciplinary action(s) should the hospital take toward those involved in response to this incident?
  • Provide your personal thoughts on this case, and discuss what, if anything, you would have done differently.

Case Study: A Tragic Medical Mistak

In early December of 1995, a seven-year-old boy was admitted to a South Florida hospital to undergo ear surgery to remove scar tissue resulting from two earlier surgeries. Although the young boy was frightened, his mother played with him beforehand and ensured him he would be fine and would even have an early Christmas surprise when he woke up from the surgery.

During the surgery, the boy would be under general anesthesia, and his ear would be injected with lidocaine and swabbed with a form of adrenaline called epinephrine. The procedure used to prepare each of these drugs for use in surgery occurs frequently and without error in hospitals all over the country. Unfortunately, on this day, a mistake occurred and the two drugs were inadvertently switched. Instead of injecting the patient with lidocaine, the physician administered a lethal dose of epinephrine directly into the boy’s ear. This immediately caused the boy’s heart rate and blood pressure to rise at an alarming rate. The head of anesthesia was rushed into the operating room (OR) to try and bring the boy’s heart rate and blood pressure down. He was able to temporarily stabilize the boy, but soon after the patient’s heart rate and blood pressure began rapidly decreasing, and then he stopped breathing. The head of anesthesia performed CPR on the patient for more than 90 minutes. While he was finally able to resuscitate the patient, it was evident that the boy was in a deep coma and would probably not recover. He was rushed to the intensive care unit and his mother was informed by the surgeon and the head of anesthesia that her son was in a coma and most likely brain dead. After keeping the boy on a ventilator for almost 24 hours, it was apparent to his parents and older sister that he was not going to regain consciousness. Therefore, the parents agreed to remove the ventilator, and the boy passed away.

The hospital’s risk manager was called in during the incident, and while the surgeons were speaking with the child’s parents, she went into the OR and collected everything that was left from that specific surgery. Initially, she decided to lock away all the syringes, vials, and cups that were used; however, once she received the details of the incident, she knew she had to send these items out to be tested by an independent lab. The risk manager promised the parents she would get to the bottom of what occurred during the surgery.

Three weeks after the boy’s death, the risk manager received the results of the independent test which were conclusive in showing that the drugs had been inadvertently switched and that the young boy had died due to human error. By this time, the family had hired malpractice attorneys. The risk manager and the head of anesthesia met with the family and their lawyers to share the results of the test and admit the truth. It was important to them and the entire hospital administration to admit this mistake to the grieving parents, determine what needed to be done to try and ease their pain, and work on a solution to ensure that such a mistake would never happen again.

An undisclosed settlement was made and the parents met with the surgeon to ask the questions that had been troubling them since their son’s death. They wanted to know if their son had suffered, if he had known he was in trouble, and, surprisingly, if they could continue using the hospital for their medical care. They also wanted to share their son’s story with everyone who would listen to ensure the same mistake would not occur again in the future. At that point, the case was closed for the family; however, the case was far from closed for the hospital.

The risk manager, CEO, head of anesthesia, and, at times, even the surgeon, traveled to conferences around the country to share the story of what had happened in their OR that day. As the story spread, the group was invited to speak at more and more conferences, both in the U.S. and, eventually, abroad. A group of physicians from Japan even traveled to the hospital to discuss the case with those involved so they could better their own procedures in the OR.

In addition to sharing the story with other medical professionals, the hospital made many internal changes to their procedures. Drugs were no longer permitted to be poured from a bottle into a cup and transferred to a syringe; the new policy is to use a special filtering device to transfer the drugs directly to a syringe. In addition, the medicines are to be placed in the syringes one at a time to ensure that there is no chance of a mix-up. The entire process must be observed by two nurses who must also verify the contents. Lastly, all medical staff have been trained not to place epinephrine into a syringe or discard any vials until surgery is finished and patients are checked for complete stabilization.

This case study is about a true occurrence that was covered in international news for many years. You can read additional details on the case, what happened after, and how things have changed in health care due to this case in the following articles:

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