Friday, November 26, 2004

Hospital Injects Woman With Cleaning Fluid

Thursday, November 25, 2004, 12:37 A.M. Pacific
Hospital details what went wrong: Woman dies from toxic injection
By Nick Perry and Carol M. Ostrom
Seattle Times staff reporters

A Seattle hospital's recent decision to switch antiseptics from a brown solution to a colorless liquid appears to have played a key role in the death of an Everett woman.
Mary McClinton, 69, a tireless worker for the disadvantaged, died early Tuesday. She was mistakenly injected with antiseptic — rather than a marker dye — during a brain-aneurysm procedure at Virginia Mason Medical Center 19 days earlier, on Nov. 4.
The hospital this week took the unusual step of publicly explaining, and apologizing for, the error.
Exactly what went wrong during the aneurysm procedure is detailed in a staff memo obtained by The Seattle Times. The memo, written by Dr. Mindy Cooper, chair of the quality-assurance committee, and Robert Mecklenburg, chief of the department of medicine, was sent to staff a week after the surgery, 12 days before McClinton died.
"The solution used to clean skin before and after procedures was recently changed from a brown iodine-based solution to a colorless antiseptic," which looks "exactly the same" as the dye, the memo states.
"At some time during the procedure, the clear antiseptic solution was placed in an unlabeled cup identical to that used to hold the marker dye ... that is injected into blood vessels to make them visible on x-rays."
The antiseptic then was injected into a main artery carrying blood to the leg, the memo says.
"The antiseptic solution is highly toxic when injected into a blood vessel. Acute and severe chemical injury to the blood vessels of the leg blocked blood flow to muscles, causing profound injury and swelling of the leg," the memo states. "Kidney failure, a sudden drop in blood pressure and a stroke followed."
The memo called the medical error a "systems problem," and while no individual is responsible, "all of us" are responsible. "We have injured her so badly that she may never again regain the life she enjoyed," the memo states.
As McClinton's condition worsened, hospital staff took drastic measures to try to save her, including amputating one of her legs below the knee. But her organs were too badly damaged.
Steven McClinton said his mother called two hours after the surgery saying "something is very wrong." He visited that night, and she was in pain, her leg badly swollen, he said.
The family camped out at the hospital watching over her, said another son, Gerald McClinton. At one point in the days following the surgery, she mouthed: "I love you" before slipping into an incoherent state from which she never fully recovered, Gerald McClinton said. He said he was holding her hand when she died.
Hit by picture
Gerald McClinton said his mother may never have known she had an aneurysm save for an odd incident at Virginia Mason two or three months earlier.
She was there for an eye procedure, and as she was sitting in a waiting room, a large picture, about 6 feet square, fell onto her head, the son said.
His mother told him that the picture "knocked her silly," Gerald McClinton said. In the days afterward she felt dizzy, so he took her to an Everett hospital where a brain scan revealed the aneurysm.
A Virginia Mason spokeswoman said last night the family "certainly are a credible source" but she could not verify the picture incident.
Mary McClinton, who moved from Alaska in 1996, dedicated her life to helping others, her family said. She was even adopted by the Tlingit tribe for her work as a vocational coordinator.
She worked at the Greater Trinity Missionary Baptist Church in Everett helping to find jobs for people with physical and mental disabilities, said Pastor Paul Stoot Sr.
"Oh man, she was a mother to everyone," Stoot said. "Everybody to her was somebody that needed love."
Her funeral will be held at noon Saturday at the Everett church, the pastor said.
"Culture of patient safety"
Virginia Mason's unusual apology, posted on its Web site Tuesday, is part of a "culture of patient safety" that has been cultivated at the medical center since the patient-safety movement swept the country in 1999, said Dr. Robert Caplan, who heads the hospital's patient-safety efforts.
"We just can't say how appalled we are at ourselves and the suffering of this patient and her family and friends," Caplan said yesterday. "We're trying in every way we can to convey our apologies to this patient for this preventable medical error. In many ways, this open and honest communication is our way of trying to honor her."
The only way to improve patient safety, he said, is to be "open and honest about our errors. ... You can't understand something you hide."
Since the error, the liquid antiseptic has been removed from the hospital and replaced with a swab on a stick.
The hospital's public mea culpa is part of a broader trend of "trying to be more transparent when there's been a harmful medical error," said Dr. Thomas Gallagher, a University of Washington internist who has studied apologies and medical errors.
Gerald McClinton said the doctors treated his family well, and he is glad the hospital did not try to hide the mistake.
"It's a mistake, a very preventable mistake," McClinton said. "I am getting angrier by the minute, although I don't know really who I should be getting angry at."
McClinton said his family has not contacted an attorney. The hospital has approached the family wanting to talk about a settlement, he added, although no meetings have taken place. "We are looking at our options at this point," he said.
Deanna Whitman, a spokeswoman for the Washington state Department of Health, said Virginia Mason had reported more "adverse events" over the past three years than three other Seattle hospitals — although she added that she thinks Virginia Mason is generally more conscientious about reporting such incidents.
"Adverse events" are mistakes that stem from systematic problems. Not all medical errors are included.
Since the start of 2002, Virginia Mason, licensed for 336 beds, has reported nine adverse events, including four that resulted in the patient dying or being left in a permanent vegetative state, Whitman said.
During the same period, Swedish Medical Center, with 1,400 beds, reported four incidents and no deaths. Harborview Medical Center, licensed for 413 beds, reported five incidents including three that were catastrophic.
The University of Washington Medical Center, with 450 beds, reported seven incidents including three that were catastrophic, Whitman said.