Maine hospital: No discipline following overdose death
The Associated Press
DOVER-FOXCROFT — Mayo Regional Hospital in Maine says there'll be no disciplinary action for staff following an overdose death in its emergency room.
The Dover-Foxcroft hospital completed an internal investigation into the death of a 51-year-old man who arrived in the emergency room suffering from an allergic reaction on June 4.
Hospital officials told the Bangor Daily News that Timothy Harvey of Atkinson died after receiving 10 times the normal dose of epinephrine, commonly known as adrenaline. The hospital immediately took responsibility for the mistake.
Marketing director Tom Lizotte says the hospital has made procedural changes to avoid a repeat. The Maine Department of Health and Human Services is doing its own investigation.
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31 COMMENTS
Crystal said...
How did he accidentally receive 10 times the normal dose?!
July 16, 2010 at 11:00 AM Report abuse
AKMaineiac said...
Just hazarding a guess here. Drugs come in various concentrations, (1%, 5%, 10%...). I suspect a doctor ordered an epinephrine injection, and the order read one way, was interpreted another, and the man ended up getting, as an example "10cc of 10%", instead of 10cc of 1%". Medication orders can be difficult to read, and interpret. It's one place where you do have to be perfect or someone is likely to be harmed or killed. Discipline for an error depends mainly on circumstances, not outcomes. As tempting as it might be to "hang the fool!", because someone was killed, that would be a mistake.
July 16, 2010 at 11:18 AM Report abuse
marvellous said...
They probably only get one allergic reaction patient a year!
July 16, 2010 at 11:19 AM Report abuse
null said...
Wow! That is screwed up. They should definitely be disciplinary action against the who person who ordered or administered the drug to this patient. Especially given the fact that they admitted to the mistake. I'm sure it's a little comforting to the deceased loved ones that they won't kill again, but it's not going to bring there loved one back.
July 16, 2010 at 11:34 AM Report abuse
Orv said...
Mayo is one of the best hospitals around and they are very busy for their size. I have seen first hand the care they administer to each patient and the professionalism of the entire staff. Mistakes happen in all hospitals. Sadly this case ended in a death.
July 16, 2010 at 11:36 AM Report abuse
AmazedAgain said...
Epi comes in a 1mg dose in 1:1000 parts of water, or a 1mg in 10,000 parts of water. It is also available in a 30mg "multi dose vial" in 30cc's of (sterile)water. If the order was written incorrectly (3.0mg vs correct of 0.3mg) you couldn't withdraw that much epi from the 1mg doses. So hospitals should eliminate the 30mg multi dose vials, and accidents like that shouldn't happen again.
July 16, 2010 at 11:50 AM Report abuse
Hipupchuck said...
Sloppy unethical work. Good thing he wasn't an 'important' person. Would would have had a new crusade and law to address it.
July 16, 2010 at 12:18 PM Report abuse
Sassy1 said...
OMG!! How in the world did that happen?? Even if that MUCH was ordered, the nurse(s) SHOULD HAVE QUETIONED THE DR.!!!!! I was a med nurse & if I had NOT questioned a Dr's med order, I would have killed this pt. It haunts me to this day!!
July 16, 2010 at 12:21 PM Report abuse
null said...
Why are doctors still writing orders down... when u goto a pharmacy you get a bottle with a lable on it why dont doctors have this technology
July 16, 2010 at 12:22 PM Report abuse
Les said...
Dang. That's a lot of adrenaline. His heart must have seized up. That's not cool.
July 16, 2010 at 12:48 PM Report abuse
laloo said...
Agreed sassy. I doubt tens times the normal dose is typically given. Any nurse that can't recognize an obvious mistake or misprint is not a nurse I want at my bedside. I'm am sure this nurse feels incredibly awful. Its horrifying to make a deadly mistake, but they should be sent on leave to brush up on their skills.
July 16, 2010 at 1:04 PM Report abuse
Iwatch said...
What a tragedy! As long as we are human, doing human tasks, there will be human error. Rare but true. Can you imagine how the responsible person must feel?
July 16, 2010 at 1:06 PM Report abuse
Y2Fyb2wz said...
Mistakes aren't allowed. My son died of the same mistake. Licenses need to be revoked
July 16, 2010 at 1:51 PM Report abuse
Y2Fyb2wz said...
Mistakes aren't allowed. My son died of the same mistake. Licenses need to be revoked
July 16, 2010 at 1:53 PM Report abuse
padman23 said...
This is one of those cases where it is important to know the people involved. If the individual has a good track record and has done good work with no problems are you going to take their license knowing that this person will never make the same mistake again. However, if there are numerous complaints and disciplinary notices that is a different story altogether...
July 16, 2010 at 2:22 PM Report abuse
Justiceall said...
Hospital contempt for their patients is at an all time high. It is almost as high as the contempt our government holds American Citizens. American citizens also now have as much contempt for these institutions as they have for us. 10% favorable opinion of our government is worse folks than the 18% of the rest of the world that has positive views of our government. Would think they would get the message.
July 16, 2010 at 2:23 PM Report abuse
null said...
AKMaineiac, "Discipline for an error depends mainly on circumstances, not outcomes. As tempting as it might be to "hang the fool!", because someone was killed, that would be a mistake." Do you think you would feel the same way if it were your spouse that died?
July 16, 2010 at 2:39 PM Report abuse
AKMaineiac said...
null said... AKMaineiac, "Discipline for an error depends mainly on circumstances, not outcomes. As tempting as it might be to "hang the fool!", because someone was killed, that would be a mistake." Do you think you would feel the same way if it were your spouse that died? *** Maybe, maybe not, I'd be heartbroken I know that. Enraged? Maybe at the injustice of it all. Gave up on justice a long time ago personally though, so it's just more of the same. Fact is, the family of the victim needs some form of reparation, despite the inability to "bring back" their loved one. Another fact, the judicial system and the hospital don't exist to exact the revenge any particular loved one of a specific victim decides is appropriate. People will call for various punishments for "guilty" people in cases where human imperfection surpassed the inanimate safeguards we put in place. We'd all like to think, "That'd never happen to me. Hang em." Better hope it doesn't... happen to you.
July 16, 2010 at 2:48 PM Report abuse
NH said...
No discipline for causing a person's death? What do you have to do in order to be held responsible for anything in a hospital system?
July 16, 2010 at 2:50 PM Report abuse
Jones824 said...
Well at least this was a mistake, Gardiner just kills people, that's right, look at it here, the complaint was recorded on digital audio. Gardiner EMT DENIES OXYGEN TO DYING GARDINER MAN HE TELLS THE MOTHER, "ITS NOT MY JOB TO STAY UP ALL NIGHT AND TAKE CARE OF SICK KIDS" (GARDINER EMT BINNETTE) http://www.gardinermaineproblems.com/page2.html(MOTHERS complaint recorded on audio)
July 16, 2010 at 2:50 PM Report abuse
Jones824 said...
I will bet they didn't tell you about this at the official Gardiner website did they?
July 16, 2010 at 3:58 PM Report abuse
BarryNobama said...
Damn that new math...
July 16, 2010 at 4:24 PM Report abuse
mainehick said...
Lets see; the same people who set the procedure that failed the patient have a new one that is bound to work. I also continue to wonder what assuming responsibility means. No leadership changes, no discipline & retraining?
July 16, 2010 at 5:14 PM Report abuse
Scrib said...
I see we have some experts here. Even though I put a great deal of trust in M.D.s, I may just opt for a massive self-administered dose of caffeine via coffee next time I have an allergic reaction...
July 16, 2010 at 5:58 PM Report abuse
dee81 said...
Wherever the error it is wrong!! If that were my child I would certainly take action to ensure that doesn't happen to anyone else!!! What were they thinking, misreading or not a nurse is certainly smart enough to know that the order must've been wrong and could've questioned it.. Isn't that why they spend years in school???? I hope that DHHS finds them liable and I hope the family takes legal action, it will never bring back their loved one but at least show them this type of mistake or reading error can't happen.
July 16, 2010 at 6:39 PM Report abuse
middleone said...
Oh, gee darn, someone made a mistake, and so what if someone died? It doesn't matter that the seriousness of the mistake resulted in death? I am not buying it. There are small mistakes, big mistakes, and catastrophic mistakes. Small ones should be ignored, the humongous ones should not be given a pass.
July 16, 2010 at 9:14 PM Report abuse
AKMaineiac said...
I'd suggest maybe having the folks involved making some appearances at nursing schools and medical schools to discuss this with groups of students. I recall nursing students having a conniption fit because they had to have at least an 85% on the medication exams... "Well, where you're going when you graduate, you'll have to have a 100% at the end of each day."
July 16, 2010 at 9:42 PM Report abuse
Caveman said...
.3% ordered/3% given! This month July) is the most likely for one to get a nosocomial (hospital acquired) infection also. Why? It's when all Med, Nurse, P.A. students graduate. I recently told a P.A. to cancel that order for me. I had an infected tonsil and he was ordering a CAT scan. The cost of that to take a picture of an infected tonsil??? CAT scans cost vary from $500 to $7,000 depending how bold the hospital. That crap is why our health costs are through the roof.
July 16, 2010 at 10:34 PM Report abuse
StovePrairie said...
I recently was a surgical patient at MMC in Portland. Within 3 days after the lengthy surgical procedure, a significant difference of objective arose between the surgical and medical teams. Complicating the immediate status was simultaneous interaction amongst post op drugs. An astute RN on staff and fully aware of my charted information contacted my personal medical group outside the hospital personnel for some objective clarification and, possibly, prevention of unnecessary abdominal surgery and expiring while in the OR. This is an example of well trained and independent staff knowing how and when to question a situation and/or its orders using acute "triage" protocol. This quite likely saved my life and kept my recovery within a standard window of inpatient time. Thank you, surgical RN staff, 6th floor, for your persistent, professional and timely response that had, at minimum, the best course of medical therapy in this post op situation. Respectfully!
July 17, 2010 at 7:57 AM Report abuse
DirkLerxst said...
Terribly sorry to hear about this. I won't pass judgement because I wasn't there. Most of you probably have no idea how you'd react to a true life threatning emergency. Not everyone can stay 100% focused, though they should. Maybe the patient was in anaphylaxis and the RN/MD panicked, grabbed the wrong vial, and pushed the wrong dose. It's not excusable and there should be an accounting, which I'm sure will be a settlement for the patients family. There's a great book to help medical professionals avoid things like this. It's called "The Checklist Manifesto" by Atul Gawande. Should be mandatory reading for all medical disciplines.
July 17, 2010 at 8:12 AM Report abuse
bubbagump said...
Epinephrine is given for allergic issues a 0.1 and 0.2 cc. It would be easy for someone not familiar with the drug or dose to make the mistake but at any rate it is tragic and the hospital did the right thing on admitting it's fault.
July 17, 2010 at 12:13 PM Report abuse